Should there be a paradigm shift for the evaluation of isthmic thyroid nodules?

PURPOSE: Although the thyroid isthmus seems like a rudimentary structure that connects bilateral lobes, it is an undiscovered area that needs to be explored. Currently, the data is evolving that the increase in the risk of malignancy is higher in the isthmic nodules, and extrathyroidal extensions and lymph node metastases are more common in isthmic-derived malignant thyroid nodules. Therefore, we aimed to compare the malignancy rate of isthmic and lobar nodules, the ultrasonographic features of isthmic and lobar nodules, and presence of lymph node metastases, distant metastases, and extrathyroidal invasions in malignant isthmic nodules. METHODS: In this retrospective study, we enrolled patients between the ages of 18-80 years, who had thyroid nodule/nodules cytology and/or pathology results from January 2009 to November 2022. 9504 nodules were selected for the analysis of US findings, cytopathology results, and malignancy rates. RESULTS: A mean ± SD age of 55.3 ± 13.0 years with a female to male ratio of [7618 (80.2%)/1886(19.8%)] were included in the study. 962 of the nodules were at isthmic localization; whereas 8542 nodules were at lobar localization. 1188 nodules were resulted as malignant from histopathological evaluation. Of the 1188 malignant nodules, 986 nodules were (83.0%) PTC, 114 nodules (9.6%) were FTC, 55 nodules were (4.6%) MTC, 16 nodules 1.3% were Hurtle cell carcinoma, 8 nodules (0.7%) were anaplastic thyroid carcinoma, and 9 nodules (0.8%) were thyroid tumors of uncertain malignant potential (TT-UMP). 156 of the malignant nodules (13.1%) were located in the isthmus, whereas the majority of the malignant nodules (n = 1032, 86.9%) were located at the lobar parts (right or left) of the thyroid. When the metastasis patterns of isthmic and lobar thyroid cancers were examined, no significant relationship was found between isthmic and lobar cancers in terms of capsule invasion (p = 0.435), muscle invasion (p = 0.294), and lymph node metastasis (p = 0.633). A significant relation was found between nodule localization (isthmus-upper-middle and lower lobes) and malignancy (p < 0.001). In our logistic regression analysis, isthmic and upper pole nodule localizations, age and TI-RADS were evaluated as independent risk factors for malignancy (p < 0.001 for all factors). CONCLUSION: We recommend nodule localization has to be considered an additional risk factor when performing a Fine Needle Aspiration Biopsy for the increased malignancy risk in this localization.

Is endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) reliable and safe procedure in geriatric patients?

BACKGROUND: Even though studies have indicated the usefulness and safety of endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA), elderly patient data are limited due to the small sample sizes. AIM: We aimed to evaluate usage and safety of EBUS-TBNA in elderly population. METHODS: This single-center retrospective study was conducted with patients who underwent an EBUS-TBNA procedure between September 2011 and December 2019. The patients were categorized into two groups: those aged 65 years or older (elderly group) and those younger than 65 years (younger group). RESULTS: 2444 patient data, 1069 of which were in the elderly group, were analyzed. The cytological examination of EBUS-TBNA identified specimen adequacy in 96.8% of patients. One hundred and thirty patients (5.3%) experienced complications, with similar complication rates recorded in both the elderly and younger groups (5.4% vs 5.2%, p: 0.836). Logistic regression analyses revealed that age, and presence of hypertension, diabetes mellitus, coronary artery disease and malignancy are associated significantly with complication-related EBUS-TBNA. For the lymph nodes with a final diagnosis of malignancy, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of EBUS-TBNA revealed a diagnostic performance in excess of 90% except for metastasis and lymphoma. CONCLUSION: EBUS-TBNA can be considered a safe and effective technique in patients aged 65 years and over.

Evaluation of lung cancer biomarkers profile for the decision of targeted therapy in EBUS-TBNA cytological samples.

BACKGROUND: Guidelines recommend performing biomarker tests for epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), BRAF and ROS proto-oncogene-1(ROS1) genes and protein expression of programmed death ligand-1(PD-L1) in patients with non-small lung cell carcinoma (NSCLC). Studies reported that endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) can provide sufficient material for cancer biomarker analyses, but there are still concerns about the subject. AIM: The purpose of the study was to assess the adequacy of EBUS-TBNA for testing lung cancer biomarkers. METHODS: We retrospectively reviewed patients with NSCLC whose EBUS-TBNA was analysed for EGFR, ALK, ROS-1, BRAF and PD-L1 expression between December 2011 and December 2020. RESULTS: A total of 394 patients were enrolled in the study. EGFR mutation and ALK fusion were the most common studied biomarkers. EBUS-TBNA adequacy rate for biomarker tests was found 99.0% for EGFR, 99.1 for ALK, 97.2% for ROS1, 100% for BRAF and 99.3% for PD-L1 testing. Multivariate analysis revealed the histological type, history of treatment for NSCL, size, or 18-fluorodeoxyglucose uptake of sampled lesion did not show any association with TBNA adequacy for biomarker testing. CONCLUSION: EBUS-TBNA can provide adequate material for biomarker testing for EGFR, ALK, ROS-1, BRAF and PD-L1 expression.

The relationship between clinicopathological parameters and PD-L1 expression level in advanced stage non-small cell lung cancer.

Introduction: Clinicopathological parameters related to programmed death ligand 1 (PD-L1) expression levels have been investigated in several studies. However, the results of these studies are conflicting and vary in different populations. This study aimed to investigate the relation of clinicopathological parameters with PD-L1 expression level in advanced stage non-small cell lung cancer patients. Materials and Methods: The patients diagnosed with non-small cell lung cancer were enrolled, retrospectively. The data of clinicopathological parameters was collected. Clinicopathological parameters in relation to PD-L1 expression levels (0%, 1-50%, and >50%) were analyzed as univariable and multivariable. Result: In total, 384 patients were enrolled. PD-L1 expression in tumor cells was between 1-50%, and >50% in 41.4%, and 23.4% of patients, respectively. There was no PD-L1 expression in 35.2% of the patients. In univariable analysis, we found that the parameters associated with PD-L1 expression levels revealed that metastatic site number, the subtype of cancer, diagnostic material type, platelet number, and LDH level were statistically significant. Adenocarcinoma frequency was higher in tumors that had PD-L1 expression >50% than in tumors that did not express PD-L1 and the difference was statistically significant (p= 0.04, coefficient= 0.3, 95% CI 0.09-0.94). Cytology as diagnostic material was significant in PD-L1 level 1-50% comparing to >50% (p= 0.02, coefficient= 2.2, 95% CI= 1.08-4.46). Conclusions: According to the results of our study, many of the clinicopathological parameters are not related to the PD-L1 level. The histological subtype and diagnostic material may affect the level of PD-L1 expression.

Calcitonin levels in washout samples vs. cytology in the detection of malignant lymph node metastasis in recurrent medullary thyroid cancer

Background/aim: Calcitonin level in fine-needle aspirate washout fluid (Ct-FNA) was extensively studied for thyroid nodules and lymph nodes (LN). However, the data was scarce for neck recurrences/metastases of medullary thyroid cancer (MTC). Thus, the diagnostic accuracy of Ct-FNA and cytology in the detection of neck LN metastases of recurrent MTC cases were assessed. Materials and methods: The database of MTC patients between 2010 and 2021 was retrospectively reviewed. A total of 32 patients with recurrent MTC and suspicious LN who underwent FNA and Ct measurement from washout samples were included in this study. Preoperative serum Ct (sCt), Ct-FNA, Ct-FNA/sCt ratio, cytology data were recorded for all participants. Results: Median sCt of 32 patients and Ct-FNA washout fluid levels of operated suspicious 44 LNs were 723 (54­9000) pg/mL and 1800 (151­9500) pg/mL, respectively. The diagnostic accuracy of Ct-FNA washout fluid was greater than cytology (95.4% vs. 86%, respectively). Using a cut-off level of >638.5 pg/mL, the Ct-FNA predicted the diagnosis of LN metastasis of recurrent MTC with a sensitivity of 80% and specificity of 94.9%. Furthermore, using a cut-off level of >1.16, the Ct-FNA/sCt ratio well predicted the diagnosis of LN metastasis of recurrent MTC with a sensitivity of 92.3% and specificity of 100%. Conclusion: As Ct-FNA has greater diagnostic accuracy in our study, it would be complementary to cytology results to localize metastatic LNs in recurrent MTC. Furthermore, for the first time, we demonstrated that the Ct-FNA/sCt ratio was a better predictor of metastatic LNs in recurrent MTC than a particular cut-off for Ct-FNA alone.

Are thyroid nodules with spongiform morphology always benign?

OBJECTIVE: Fine needle aspiration (FNA) biopsy for evaluation of spongiform nodules ≥20 mm or observation without FNA was recommended by American Thyroid Association. However, this was a weak recommendation supported by moderate quality evidence. We aimed to assess malignancy risk in spongiform nodules. METHODS: From January 2015 to June 2016, an experienced endocrinologist performed B-mode greyscale ultrasonography and observed 96 spongiform nodules among 3748 ultrasound procedures. Power Doppler ultrasonography and ultrasound-guided FNA were performed to 96 spongiform nodules. Both colour elastography and strain ratio measurements of dominantly solid areas were performed. RESULTS: All spongiform nodules had benign cytology. Fifty-two (54.2%) nodules were ≥20 mm and 44 (45.8%) were smaller than 20 mm in maximum diameter. Presence of ultrasonography features related to malignancy was rare; 2% (n = 2) microcalcification, 9.4% (n = 9) taller than wide shape and 2% (n = 2) marked central blood flow were noted. None of the nodules had two or more suspicious features. Ultrasound elastography findings revealed that dominantly solid components of nodules were usually soft as 66.7% had an elasticity score 1 according to colour scale and mean strain ratio was 1.39 ± 0.99. CONCLUSIONS: Follow-up with ultrasonography seems to be an efficacious method even for spongiform nodules larger than 2 cm. Determination of soft appearance according to colour map on ultrasound elastography and low strain ratio values of dominantly solid areas may be useful to avoid unnecessary biopsies.

Intranodal Palisaded Myofibroblastoma: Radiological and Cytological Overview.

BACKGROUND: Intranodal palisaded myofibroblastoma is a benign and very rare mesenchymal neoplasm of the lymph nodes originating from differentiated smooth muscle cells and myofibroblasts. CASE REPORT: We report a case of intranodal palisaded myofibroblastoma in an 84-year-old woman with Parkinson's disease that presented as a left inguinal mass. The diagnosis was made using ultrasound-guided fine needle aspiration biopsy and consequent cytopathological examination that included immunohistochemical analysis. Herein, we discuss the presentation of a rare intranodal palisaded myofibroblastoma with emphasis on its ultrasonographic and cytopathologic features. CONCLUSIONS: Intranodal palisaded myofibroblastoma should be considered in the differential diagnosis of inguinal lymphadenopathy and the diagnosis is possible with cytopathologic exam and immunohistochemical analysis using ultrasound-guided FNA biopsy, guiding the clinician to nodal excision rather than aggressive measures.

Idiopathic Pulmonary Hemosiderosis With Allergic Asthma Diagnosis in a Pediatric Patient.

Idiopathic pulmonary hemosiderosis (IPH) is a rare disorder with unknown pathogenesis that usually presents in the first decade of life. As a result of diffuse alveolar hemorrhage, respiratory symptoms such as cough attacks, hemoptysis, dyspnea, and recurrent and refractory iron-deficiency anemia (IDA) are observed. We present an 8-year-old girl who was followed up with recurrent IDA and allergic asthma and later diagnosed with IPH. IPH was confirmed by the presence of hemosiderin-laden macrophages in bronchoalveolar lavage obtained by bronchoscopy and exclusion of the secondary causes of pulmonary hemosiderosis. Glucocorticoids and iron supplementation were started. Clinical and laboratory improvement was observed with therapy. Our case illustrates that refractory/recurrent IDA with any pulmonary symptoms may be the only presenting feature of IPH.

Intrathyroidal Ectopic Thymus in Children: Retrospective Analysis of Grayscale and Doppler Sonographic Features.

OBJECTIVES: The purpose of this study was to define grayscale and color Doppler sonographic features of an ectopic intrathyroidal thymus and to differentiate it from other thyroid nodule etiologies. METHODS: We retrospectively reviewed imaging findings from 30 children who had a diagnosis of an ectopic intrathyroidal thymus from November 2005 to January 2013. Nodular thyroid lesions that were enclosed by the thyroid parenchyma and showed a typical echo pattern consistent with the thymus were accepted as the enclosed form of an intrathyroidal ectopic thymus. Eleven of these 30 children had an intrathyroidal ectopic thymus enclosed by the thyroid parenchyma, and they were enrolled in the study. The recorded sonograms were reviewed according to side, location, size, shape, echo pattern, internal content, and vascularization. RESULTS: The enclosed forms of ectopic intrathyroidal thymuses were unilateral in all children and located in the mid portion (n = 10) or lower portion (n = 1). All lesions were well demarcated, and the most common shape was fusiform (n = 8). Nine lesions showed a typical hypoechoic echo pattern with internal linear and punctate echoes resembling a mediastinal thymus. On color Doppler imaging, 6 lesions showed hypovascularity compared to the thyroid parenchyma, and 5 lesions showed internal vascularity. CONCLUSIONS: Unique sonographic features of the enclosed form of an ectopic intrathyroidal thymus, including a hypoechoic echo pattern with multiple linear and punctate echoes, a fusiform shape, a well-demarcated contour, and a mid- or low-lying location with hypovascularity or internal vascularity, can help radiologists differentiate it from other thyroid nodule etiologies.

Acute suppurative thyroiditis following fine-needle aspiration biopsy in an immunocompetent patient.

The thyroid gland is remarkably resistant to infectious agents owing to several protective mechanisms. Acute suppurative thyroiditis after fine-needle aspiration (FNA) in an immunocompetent patient is very rare. We report the case of a 50-year-old immunocompetent male patient who presented with painful cervical swelling, fever, and chills after an FNA of the thyroid. His physical and laboratory examination suggested an acute suppurative thyroiditis. Repeat FNA results were consistent with thyroid abscess. Physicians should be aware of the probability of acute bacterial thyroiditis after FNA.

Use of Endoscopic Ultrasound Elastography to Differentiate between Gastrointestinal Stromal Tumor and Leiomyoma Localized in the Upper Gastrointestinal Tract.

Background: Gastrointestinal stromal tumors (GISTs) have malignant potential. Distinction of GISTs from leiomyoma is important to the decision of follow-up or treatment for upper gastrointestinal tract subepithelial lesions (SELs). There are few studies on the evaluation of gastrointestinal SELs with endoscopic ultrasound (EUS) elastography. Aims: To evaluate the efficiency of strain ratio (SR) measurement and Giovannini's classification (Gc) by EUS elastography in differentiating GISTs from leiomyomas. Materials and methods: Twenty-three lesions with histopathological diagnoses of 13 GISTs and 10 leiomyomas were evaluated. The lesions' SR values were obtained from EUS reports retrospectively. Giovannini's classification was performed according to the elastography images recorded in the system. The effectiveness of SR and Gc in the distinction between GIST and leiomyomas was evaluated. Results: Twelve of the GISTs and 3 of the leiomyomas were with scores 4 and 5 according to Gc (p = 0.006). Gastrointestinal stromal tumors had a higher SR than leiomyomas (p = 0.001). For the diagnosis of GISTs, sensitivity/specificity/diagnostic accuracy were 92.3%/80%/87% for SR alone, 92.3%/70%/82.6% for Gc alone, and 84.6%/80%/82.6% for the use of both SR and Gc. Conclusions: This is the first study in which semi-quantitative (SR) and qualitative (Gc) methods were evaluated together for the distinction of GISTs and leiomyomas. The sensitivity of SR alone for diagnosing GIST is higher than that of Gc alone or the combination of both methods. Although SR alone does not diagnose GIST, it can be used as an auxiliary method in biopsy and follow-up decisions. How to cite this article: Erdem RE, Bektas M, Ellik ZM, et al. Use of Endoscopic Ultrasound Elastography to Differentiate between Gastrointestinal Stromal Tumor and Leiomyoma Localized in the Upper Gastrointestinal Tract. Euroasian J Hepato-Gastroenterol 2024;14(1):20-23.

Importance of mediastinal granulomatous/sarcoid-like lymphadenopathy in extrathoracic malignancies.

BACKGROUND: In patients with extrathoracic malignancies (ETM), granulomatous lymph adenopathy called sarcoid-like reactions (SLR) can be seen in the regional or draining lymph nodes. We hypothesized that SLR may be a sign of imminent metastasis and investigated the clinical course and rate of recurrence in patients with ETM and granulomatous mediastinal lymphadenopathy (MLN). METHODS: In this retrospective observational study, we reviewed the medical files of patients with known ETM and who underwent EBUS-TBNA for initial staging or detection of recurrence from 2011 to 2023. Patients with granulomatous MLN were included. RESULTS: Forty-one patients (29 female) enrolled in the study. Breast and colorectal carcinomas were the most common malignancies. A total of 81 lymph nodes were sampled. The final diagnosis of patients was five sarcoidosis, one tuberculosis, one second primary, one drug reaction, and 33 SLR. Among patients with SLR, in one patient lymph nodes progressed during the follow-up and were accepted as false-negative without confirmatory biopsy. The negative predictive value (NPV) of granulomatous MLN for metastasis was 97.05%. CONCLUSION: Granulomatous MLN may be due to tuberculosis, drug reaction, sarcoidosis, or SLR in patients with ETM. SLR has a high NPV in patients with ETM. Follow-up imaging rather than confirmatory biopsy is reasonable in these patients.

Familial Clinical Heterogeneity of Medullary Thyroid Cancer with Germline RET S891A Protooncogene Mutation: 7-Year Follow-up with Successful Sorafenib Treatment.

Hereditary forms of Medullary thyroid carcinoma (MTC) are rare. Different phenotypes with the same mutation may be due to differences in the timing of RET activation steps, additional mutations in other regions of the gene, or the co-occurrence of germline and somatic mutations, which is an infrequent possibility. Here, we aim to present the different features and difficulties in the follow-up of three family members with the same germline mutation. A 4-year-old male patient with respiratory distress was diagnosed with MTC and found to have a heterozygous germline mutation C.2671T>G(S891A) in the RET gene (classified as intermediate risk according to ATA). As the tumor was inoperable, treatment with a tyrosine kinase inhibitor (sorafenib) was initiated. Sorafenib has prevented tumor progression for seven years. Whole exome sequencing (WES) did not identify additional mutations. Segregation analysis showed the same mutation in the asymptomatic mother and sister. In our case, thyroid tissues were examined for somatic mutations, and SDHA c.1223C>T (p.S408L) was found. The clinical presentation of rare mutations such as RET p.S891A differed among family members carrying the same germline mutation. Our index case's more severe clinical presentation may be due to an additional somatic mutation. Sorafenib treatment can be an option for advanced MTC and may prevent disease progression.

Contribution of small tissue biopsy and flow cytometry to preoperative cytological categorization of salivary gland fine needle aspirates according to the Milan System: Single center experience on 287 cases.

BACKGROUND: Milan system for reporting salivary gland cytopathology (MSRSGC) was proposed to provide a standardized reporting system for salivary gland fine needle aspiration biopsies. Modified Menghini type semi-automatic aspiration biopsy needles provide small tissue fragments (STFs), as well as cellular smears, and immunohistochemical and molecular studies can be performed using the STFs. AIMS: We aimed to evaluate the contribution of STFs and ancillary techniques to pre-operative diagnosis of salivary gland lesions. MATERIALS AND METHODS: In this study, smears of 287 cases with histopathological correlation were re-reviewed and assigned to one of the MSRSGC categories. In the second step, histopathological and immunohistochemical findings in STFs were evaluated together with cytological findings. Final diagnoses were obtained with the inclusion of flow cytometry (FC) results when available. Risk of malignancy (ROM) was calculated for each diagnostic category. RESULTS: In the evaluation based on smears, a specific diagnosis could be obtained in 64.8% of the cases. ROMs were 0% for nondiagnostic (ND), 5.6% for non-neoplastic (NN), 55% for atypia of undetermined significance (AUS), 0.6% for benign neoplasm (BN), 27.8% for salivary gland neoplasm of uncertain malignant potential (SUMP), and 100% for suspicious for malignancy (SFM) and malignant (M) categories. With the addition of histopathological and immunohistochemical findings and FC results, a specific diagnosis could be obtained in 75.2% of the cases. ROMs were 0% for ND, 4.5% for NN, 53.8% for AUS, 0.6% for BN, 0% for SUMP, and 100% for SFM/M categories. CONCLUSIONS: STFs contribute correct categorization of salivary gland lesions. The major contribution of ancillary methods is in the SUMP category.

Transretinal biopsy via 23-gauge pars plana vitrectomy for retinal and choroidal tumors: cytopathological results, surgical complications, and patient outcomes.

PURPOSE: To evaluate the cytopathological results, surgical complications, and patient outcomes after transretinal biopsy (TRB) for diagnosis of retinal/choroidal tumors METHODS: Records of 40 cases who underwent TRB via 23-gauge (23 G) pars plana vitrectomy between March 2011 and March 2020 were reviewed. STUDY DESIGN: Retrospective. RESULTS: Twenty-six (65.0%) cases were women and 14 (35.0%) were men. The mean age at diagnosis was 57.2 (range: 18-83) years. The mean tumor base diameter was 12.0×9.8 mm and the mean tumor thickness was 4.9 mm. According to cytopathological examination, 29 (72.5%) cases had choroidal melanoma, 2 (5.0%) had non-small cell lung cancer metastasis, 1 (2.5%) had adenoma of retinal pigment epithelium, 1 (2.5%) had small cell lung cancer metastasis, 1 (2.5%) had invasive breast cancer metastasis, 1 (2.5%) had retinal astrocytic hamartoma, and 1 (2.5%) had pseudoneoplastic gliosis. Cytopathological examination of 4 (10.0%) cases revealed findings consistent with macular and extramacular degeneration. Postoperative complications were mild vitreous hemorrhage in 16 (40.0%) cases, gradually worsening cataract in 4 (11.8%), retinal detachment in 1 (2.5%), hyphema in 1 (2.5%), glaucoma in 1 (2.5%), and macular hole in 1 (2.5%). During the mean 11.1 (range: 1-55) months follow-up, 1 (3.4%) patient with choroidal melanoma developed liver metastasis. All patients were alive at the end of follow-up. CONCLUSIONS: TRB using 23 G pars plana vitrectomy can be used to make the cytopathologic diagnosis of retinal/choroidal tumors whenever the clinical diagnosis is not certain or in cases with known diagnosis to obtain information on cell type/cytogenetics. In our series, the most common diagnosis after cytopathologic examination was choroidal melanoma.

Allogeneic stem cell transplantation for relapsed primary central nervous system lymphoma: Is it feasible?

Primary central nervous system lymphoma (PCNSL), has an aggressive course and in untreated patients median survival is limited to three months. For relapsed PCNSL, the treatment options are few and results are usually unsatisfactory. Allogeneic Hematopoietic Stem Cell Transplantation (allo-HCT) has been widely used for treatment of relapsed/refractory NHL patients. However there are limited data whether graft versus lymphoma effect can work in PCNSL patients. Here, we present a relapsed refractory PCNSL case treated by allo-HCT.

The influence of thyroid nodule size on the diagnostic efficacy and accuracy of ultrasound guided fine-needle aspiration cytology.

BACKGROUND: Diagnostic accuracy of fine-needle aspiration cytology (FNAC) in large and subcentimeter nodules is still debated. We aimed to evaluate the impact of nodule size on efficacy of the ultrasound-guided FNAC. METHODS: B-mode grayscale ultrasound (US), US-guided FNAC according to Bethesda system and histopathological data of 514 nodules from 371 patients, who underwent thyroidectomy were examined retrospectively. Nodules were grouped by maximal diameter; group A nodules were smaller than 10 mm (n = 59), group B nodules were between 10 and 29 mm (n = 218), and group C nodules were 30 mm or greater (n = 130). RESULTS: Sensitivity, specificity, and accuracy of FNAC was 92.0%, 100%, and 95.1% in group A, 80.7%, 99.1%, and %92.9 in group B, 70.0%, 98.9%, and 95.8% in group C nodules, respectively. The prevalence of papillary thyroid cancer (PTC) and incidental PTC were 44.2% (n = 164) and 6.4% (n = 24), respectively. Malignancy rate was more frequent in group A when compared to groups B and C (P < 0.01). Nodule size was positively associated with follicular cancer risk (P = 0.009). The thyroid stimulating hormone level was positively associated with malignancy (P = 0.02) and optimal cut-off value was 0.96 mIU/L. False-negative rate was 8.0%, 19.3%, and 30.0% in groups A, B, and C nodules, respectively. CONCLUSIONS: Although the malignancy rate was low in nodules ≥30 mm, diagnostic surgery for large nodules should be considered because of decreased reliability of FNAC, ineffectiveness of clinical and sonographic criteria. False-negative rate was relatively low and malignancy rate was high in subcentimeter nodules, supporting the accuracy of FNAC.

Diagnostic Value of S100p, IMP3, Maspin, and pVHL in the Differantial Diagnosis of Pancreatic Ductal Adenocarcinoma and Normal/chronic Pancreatitis in Fine Needle Aspiration Biopsy.

INTRODUCTION: Differentiation between pancreatic ductal adenocarcinoma (PDAC) from benign mimickers is a well-known problem in cytological materials. Recent studies incorporated biological markers into this question and some studies showed that expression of S100P, IMP3, and maspin as well as nonexpression of von Hippel-Lindau gene product (pVHL) were significantly correlated with PDAC. In this study, we aimed to investigate diagnostic value of maspin, IMP3, S100P, and pVHL immunostaining in fine needle aspiration biopsies (FNABs) of pancreatic lesions. MATERIALS AND METHOD: In all, 33 cases of FNAB cell blocks of PDAC and 34 cases of surgical non-neoplastic pancreas specimens which were retrieved from the archives slides from 2007 to 2011 were included in this study. All the cases were stained with maspin, IMP3, S100P, and pVHL. Expression patterns of markers were scored and compared with benign mimickers. Test performance of each antibody and possible antibody combinations were also evaluated. RESULTS: The study was composed of 33 PDAC and 34 control cases (8 chronic pancreatitis, 3 mucinous cystic neoplasm, and 23 nontumoral pancreatic tissue of PDAC). Diagnostic sensitivity for malignancy in S100P, IMP3, and maspin was 84.8%, 81.8%, and 87.5%, respectively. Specificity of these three markers was 100%. Sensitivity and specificity of pVHL for detecting nontumoral pancreatic tissue were 100% and 81.8%, respectively. When maspin, IMP3, and S100P expression were used together as triple test, sensitivity was 62.5% and specificity 100%. However, when any two of each three markers were evaluated (triple test/dual response), sensitivity reached 93.8% and specificity 100%. CONCLUSION: We observed that dual response in triple test (positive staining with two of these three markers) of maspin, IMP3, and S100P immunocytochemistry is very sensitive and specific in differential diagnosis of PDA and non-neoplastic pancreatic lesions. pVHL may have an additional role, when triple assessment is not satisfactory.

Fine needle aspiration biopsy features with histologic correlation in mediastinal hepatoid yolk sac tumor presenting with sternum metastasis: a case report.

BACKGROUND: The hepatoid variant of yolk sac tumor (H-YST) is an exceedingly rare and highly malignant neoplasm. We present and discuss our experience with cytologic and histopathologic features of a mediastinal H-YST presenting with sternum metastasis, which to the best of our knowledge has not been previously reported. CASE: A 38-year-old man presented with a large mass on the sternum. Computed tomography of the thorax showed a large anterior mediastinal mass with sternum metastsis and multiple lung metastases. Laboratory examination revealed elevated serum alpha-fetoprotein (60,000 IU/mL). No tumor was found in the other organ systems. A percutaneous fine needle aspiration biopsy and subsequent open surgical biopsy were performed on the sternum metastasis. Cytologically, the tumor was composed of monotonous, large, round to polygonal hepatoid cells forming solid sheets and trabeculae entrapped with endothelial cells resembling hepatocellular carcinoma. Histopathologic sections of tumor showed tumor cells with eosinophilic to clear cytoplasm arranged in a solid, trabecular growth pattern, with some acinar formations. Immunohistochemical study supported the hepatoid origin. CONCLUSION: Fine needle aspiration cytology, together with the characteristic clinical presentations and specific tumor markers, is crucial to the initial diagnosis of H-YST.