Special report. Immunocytochemistry in diagnostic cytology: a 12-year perspective.

In recent years immunocytochemistry has become an important addition to diagnostic cytology. Its routine application in cytology, however, has not yet reached the practical levels it has achieved in diagnostic histopathology. This review examines the values and limitations of immunocytochemistry in diagnostic cytology and addresses some of the most common technical and analytical factors that can affect the outcome of the procedure.

Lymphangioma circumscriptum of the vulva: case report and review of the literature.

Lymphangioma circumscriptum is a benign disorder of lymphatic channels. The pathology consists of a collection of subcutaneous lymphatic cisterns communicating through dilated channels with superficial clusters of vesicles. The most common symptom is recurrent oozing of clear fluid. Management consists of wide excision, assuring free lateral and deep margins by frozen-section analysis. Involved margins have been shown to increase the recurrence rate. Laser vaporization has been used recently with relatively good results. The etiology of this lesion is unclear; however, lymphatic obstruction has been suggested as a possible cause in occasional cases. Two cases of vulvar lymphangioma circumscriptum have been reported previously in the literature, both arising in elderly women after radiation therapy for squamous cell carcinoma of the cervix. We present the third case, arising in a 42-year-old woman with no previous surgery or radiation.

Malignant melanoma of the vulva.

During the years 1969 to 1982, 16 patients with primary malignant melanoma of the vulva were entered into the Tumor Registry at the University of Miami Jackson Memorial Medical Center. The mean age was 55, with a range of 18 to 89 years. Treatment was primarily by radial vulvectomy with bilateral groin and pelvic node dissection. Survival was correlated to FIGO staging, Clark and Breslow classifications, and lymph node involvement. Survival correlated best to tumor thickness and Clark levels. Patients with Clark level 2 or less and less than 1.5 mm depth of penetration had the best prognosis. Lymph node involvement was present in 25% of the patients, and there were no survivors in this group. There were no instances of positive pelvic nodes when the groin nodes were negative, and routine pelvic lymphadenectomy is not recommended.

Fine-needle aspiration cytology of the ovary.

FNA cytology has been shown to be highly accurate in diagnosing malignant tumors. In gynecology, an overall accuracy of 94.5% in the differentiation between benign and malignant tumors has been reported. Despite many controversial views regarding its safety, aspiration cytology has been accepted as an innocuous procedure that can be accomplished with minimal discomfort or complications and, in association with laparoscopy, assist in the management of ovarian cysts and masses. Although FNA cannot be considered the first-hand diagnostic procedure for ovarian cancer in postmenopausal patients, it may be extremely helpful in young women, even during pregnancy, to safely differentiate functional and other benign ovarian cysts from malignant ones. In postmenopausal women, especially those in the high risk group for surgical procedures and those undergoing a "second look" intervention following radiation or chemotherapy, aspiration cytology may provide sufficient information to warrant abandoning unnecessary surgery. During laparotomy for suspected unilateral disease, FNA may provide sufficient data about the opposite ovary to allow that organ to remain in place, thus preserving its function in a young patient. The pathologist must be familiar with the cytology of normal pelvic structures and the diagnostic criteria used to differentiate benign from malignant lesions, as well as potential diagnostic pitfalls, such as interpretation based on very few cells or the absence of appropriate clinical information. Although proper classification of ovarian masses can be achieved through FNA, the pathologist should be aware of its limitations, such as difficulties in differentiating adenomas from non-neoplastic cysts, and tumors of low malignant potential from well-differentiated carcinomas. Descriptive histologic terminology should be applied, and terms such as "suspicious" or "atypical" avoided. The aspirated material may not only be used for the diagnosis and classification of ovarian neoplasms, it may also be used for DNA analysis, detection of estrogen receptors and other prognostic markers, thus providing information regarding biologic behavior of the tumors. Finally, it is hoped that aspiration of ovarian lesions routinely detected by sonography, in elderly women or those with a strong family history of ovarian cancer, will allow the physician to accomplish detection of early ovarian cancer.

Brain metastases in malignant pleural mesothelioma. Case report and review of the literature.

Recent advances in pleural malignant mesothelioma include the sequential use of palliative surgery, perioperative radiation therapy, and systemic chemotherapy. Radical treatments may not only palliate but also improve survival in some patients. The latter may be associated with the appearance of metastases in unusual sites including the central nervous system. In malignant mesothelioma, brain metastases were previously reported in 19 patients at autopsy and in only 1 patient antemortem. We detail the clinical presentation in the second patient with pleural malignant mesothelioma thus far reported to develop brain metastases. The difficulties in diagnosis, the role of immunoperoxidase stains in malignant mesothelioma, excellent tolerance of different modalities of treatment, and a review of the literature of brain metastases in mesothelioma are discussed. Based on our report, the possibility of brain metastases should be investigated by careful clinical examination prior to a radical treatment in patients with progressive refractory mesothelioma.

Immunohistologic identification of fungi in systemic and cutaneous mycoses.

Using specific antibodies and the peroxidase-antiperoxidase technique, we were able to demonstrate a variety of fungal organisms in smears and sections of formaldehyde-fixed, paraffin-embedded tissue. The procedure is simple, fast, and accurate and may be used as an alternative to, or in conjunction with, cultural methods to identify fungi specifically.

Vulvar Paget's disease. Is immunocytochemistry helpful in assessing the surgical margins?

From January 1977 to December 1988, 19 patients with biopsy-proven Paget's disease of the vulva underwent simple or radical vulvectomy at the University of Miami/Jackson Memorial Medical Center. All vulvectomy specimens were evaluated immunocytochemically for the expression of carcinoembryonic antigen (CEA), epithelial membrane antigen (EMA) and low-molecular-weight keratins 8 and 18 (LMK), both in areas containing neoplastic cells and in histologically negative surgical margins. Neoplastic Paget's cells stained positively for CEA in all cases; they were positive for EMA and LMK in 18 and 17 cases, respectively. In all eight cases with underlying in situ or invasive carcinomas, CEA, EMA and LMK were localized in the underlying tumors as well. None of the histologically proven negative margins reacted for CEA, EMA or LMK on immunocytochemistry. CEA appears to be a valuable immunocytochemical marker for extramammary Paget's disease; EMA and LMK are also expressed by the majority of such cases. None of these markers, however, is of added value in identifying Paget's cells in surgical margins if those margins appear negative on routine hematoxylin-and-eosin staining.

Retrospective c-erbB-2 immunostaining in aspiration cytology of breast cancer.

Fifty fine-needle aspiration cytologies of breast that were diagnosed as carcinomas were retrieved from the files and retrospectively evaluated for the expression of c-erbB-2 oncoprotein using standard immunocytochemical methods. Corresponding histologic sections of all tumors were similarly studied. Seventeen fine-needle aspirates (34%) reacted positively for the presence of c-erbB-2 oncoprotein. All but one (32%) of the corresponding tissue sections were also positive for c-erbB-2 by immunohistochemistry. All positive cases were infiltrative ductal carcinomas with a preponderance of the comedo type. Positive reactions were localized in the cytoplasmic membrane of tumor cells. The staining was either present in all cells throughout a tumor, or it was completely absent. We conclude that immunocytochemistry for c-erbB-2 oncoprotein can be performed on fine-needle aspiration cytology samples that are previously fixed and stained with the Papanicolaou technique. Furthermore, the sensitivity of immunostaining results are comparable to that obtained in histologic sections.

Metastatic medullary thyroid carcinoma in liver diagnosis by aspiration cytology.

A case of metastatic medullary thyroid carcinoma (MTC) to the liver of a patient with multiple endocrine neoplasia (MEN) Type IIb was suggested by percutaneous fine-needle aspiration cytology and confirmed by histology and immunohistochemistry. The cytologic presentation of this unusual thyroid cancer in liver has not been previously reported. We report such a case and discuss its differential diagnosis from other metastatic tumors of the liver.

The value of fine-needle aspiration cytology in the diagnosis of inflammatory pancreatic masses.

In order to determine the accuracy of fine-needle aspiration cytology (FNAC) in the diagnosis of inflammatory pancreatic masses (pseudocyst and abscess), we reviewed 91 FNAC specimens performed during 1985-1989 at the University of Miami/Jackson Memorial Medical Center. All specimens were collected under computed tomographic guidance. A sensitivity of 100% and a specificity of 98% were recorded in the diagnosis of inflammatory pancreatic masses. The sensitivity and specificity of the method in the diagnosis of malignant neoplasms were 79.5% and 100%, respectively. We conclude that fine-needle aspiration cytology of pancreas is not only an important diagnostic tool in patients with pancreatic cancer, but can also be used to diagnose inflammatory masses of the pancreas. In fact, aspiration of such masses may not only be diagnostic, but also therapeutic in some patients.

Aspiration cytology of ovarian neoplasms. A review.

Unlike other gynecologic tumors, which are accessible to inspection and biopsy, ovarian neoplasms are located within the pelvis or abdomen and are reachable only by laparoscopy or exploratory laparotomy. Because of its simplicity, fine needle aspiration cytology may be used as an alternative to surgical procedures. However, because of the great variety of tumor types in the ovary, cytologic interpretation of aspirates from that organ represents one of the most challenging fields in diagnostic cytology. Nevertheless, as clinicians become more experienced in using this technique and pathologists gain confidence in their ability to evaluate samples correctly, aspiration cytology may prove to be one of the most valuable and acceptable tools in the diagnosis of tumors of the female pelvis.

Diagnosis of cryptococcal osteomyelitis by fine needle aspiration cytology a case report.

An unexpected cryptococcal infection in a patient with a history of multiple neoplasms was diagnosed by fine needle aspiration cytology as a solitary rib lesion. Speciation of the organism was confirmed by histochemical stains and culture of the aspirated material. This case reemphasizes the value of fine needle aspiration cytology in diagnosis and follow-up of patients with suspected or proven malignancies.

Cell proliferative activity and mutation of P53 suppressor gene in human gestational trophoblastic disease.

Cell proliferative activity and the overaccumulation of P53 suppressor gene were evaluated in 26 cases of gestational trophoblastic disease and five cases with normal placentae. Formalin-fixed, paraffin-embedded histological sections were used for immunohistochemistry, utilizing the avidin-biotin-peroxidase technique and antibodies to PCNA (proliferative cell nuclear antigen) and to P53 (product of suppressor gene). Positive reactions for PCNA were graded from 1+ to 3+ (1(+)-less than 10% of cells; 2(+)-10-50%; 3(+)-more than 50%). Eight of 10 cases of choriocarcinoma (80%) showed moderate to strong reactivity for PCNA (2+ and 3+). All 9 cases with hydatidiform mole and 6 of 7 cases with partial mole also demonstrated 2+ and 3+ reactions for PCNA. There was minimal or no PCNA staining in the trophoblastic cells of normal placentae. Five of 10 cases with choriocarcinoma (50%) exhibited P53 overaccumulation as did 7 of 9 cases with hydatidiform mole (78%). In hydatidiform moles, P53 staining was limited to the areas of trophoblastic proliferation separate from chorionic villi. None of the partial moles or normal placentae showed P53 overaccumulation. It is concluded that the cell proliferative activity of choriocarcinomas as well as complete and partial hydatidiform moles are comparable. On the other hand, the mutation of P53 suppressor gene, as demonstrated by the overaccumulation of P53 protein, is seen only in true trophoblastic neoplasms, namely, choriocarcinomas and hydatidiform moles.

Fine-needle aspiration cytology of palpable lesions of the lower female genital tract.

During January 1978 through May 1989, 232 fine-needle aspirations of palpable lesions of the vulva, vagina, inguinal area, and perineum were performed on 209 women. Five samples were considered inadequate for cytologic evaluation. Eighty-seven (38.3%) aspirates were interpreted as malignant, 80 of which were further classified into specific cell types. Most malignant neoplasms represented metastases from other gynecologic organs. Of the 140 (61.7%) nonmalignant aspirates, only 28 (20%) could be categorized into specific pathologic disorders. The false-positive and false-negative rates were 0 and 4.6%, respectively. We conclude that, because of its safety, simplicity, and accuracy, fine-needle aspiration cytology represents a valuable diagnostic tool in the evaluation of palpable lesions of the lower female genital tract. This technique is particularly helpful in the assessment of primary, metastatic, or recurrent malignant neoplasms of this region.

Histologic markers in primary and metastatic tumors of the liver.

To investigate the value of different tissue markers in the histologic diagnosis of hepatic tumors, we performed immunoperoxidase stains for alpha-fetoprotein (AFP), alpha-1-antitrypsin (AAT), carcinoembryonic antigen (CEA), and an erythropoiesis-associated antigen (ERY-1) on formalin-fixed, paraffin-embedded samples from 107 primary and metastatic tumors of the liver. AFP was present in 17% of the hepatocellular carcinomas, in 7% of the metastatic carcinomas, and in none of the cholangiocarcinomas. AAT was present in 41% of the hepatocellular carcinomas, in 37% of the cholangiocarcinomas, and in 50% to 70% of the metastatic carcinomas of the liver. Intracytoplasmic CEA was found in 75% of the cholangiocarcinomas, in 92% to 100% of the metastatic carcinomas, and in only one of the mixed hepatocellular-cholangiocarcinomas. ERY-1 was present in 89% of the hepatocellular carcinomas, whereas none of the cholangiocarcinomas or metastatic carcinomas stained for this marker. We conclude that immunohistochemical assays for AFP and AAT are of limited value in the differential diagnosis of hepatic tumors. However, immunohistochemical stains for ERY-1 and CEA can be valuable in differentiating hepatocellular carcinomas from metastatic tumors.

Monoclonal antibody ERY-1 identifies an antigen in erythroid cells, hepatocellular and renal cell carcinomas.

We have identified a monoclonal antibody (ERY-1), which reacts with erythrocytes, erythroid precursor cells, and with embryonal yolk sac, and normal liver and kidney. The antibody also decorates the neoplastic cells of hepatocellular, renal, and yolk sac carcinomas. No reactivity was seen in a variety of other epithelial or mesenchymal neoplasms. It is possible that ERY-1 recognizes an erythropoiesis-associated antigen present in yolk sac, kidney, liver, and bone marrow, all of which are involved in erythropoiesis in various stages of human development. Furthermore, ERY-1 has proved to be extremely useful in the histopathologic diagnosis of hepatocellular and renal cell carcinomas.

Mutagenic potential of a 193-nm excimer laser on fibroblasts in tissue culture.

In response to concerns regarding possible DNA damage by far ultraviolet radiation during excimer laser corneal surgery, the mutagenic potential of an argon fluoride excimer laser (193 nm) on BALB/3T3 mouse fibroblasts grown in tissue culture was investigated. The cumulative incidence of anaplastic transformation after subablative radiant exposures from 3.5 mJ/cm2/pulse to 13.4 mJ/cm2/pulse was 3.6% of all cell cultures. The incidence of anaplastic transformation in nonirradiated controls was 4.2%. Transformation after exposure to x-ray radiation (60.9 rad) was 98.8%. The difference between the incidence of transformation of nonirradiated controls or excimer-treated cultures compared with x-ray radiation-treated cells was significant P less than 0.0001 (chi square test). In this standard cell line, 193-nm laser energy does not appear to have substantial mutagenic potential.

Sputum examination for the diagnosis of Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome.

The diagnostic utility of sputum examination in patients with Pneumocystis carinii pneumonia secondary to the acquired immunodeficiency syndrome (AIDS) has so far not been determined. Sputum was induced in 43 patients with AIDS or suspected AIDS just prior to fiberoptic bronchoscopy, scheduled because of an unexplained pulmonary infiltrate on a chest radiograph. Pneumocystis carinii pneumonia was diagnosed by sputum examination and/or by a bronchoscopic procedure in 20 patients. Of these, sputum samples were positive for Pneumocystis organisms in 11 (55%) of 20 patients tested, bronchial washings were positive in 11 (79%) of 14 patients tested, brush biopsies were positive in 9 (53%) of 17 patients tested, and transbronchial lung biopsies were positive in 18 (90%) of 20 patients tested. The presence of P. carinii cysts in sputum did not correlate with the presence of alveolar macrophages in sputum nor with the volume of sputum. Sputum examination for P. carinii organisms, employed as a first diagnostic step in patients with AIDS with pulmonary infiltrates, may frequently obviate the need for bronchoscopy.

Cresyl violet: a rapid, simple, easily interpretable stain for detecting Pneumocystis carinii in sputum.

Over a three-month period at the pathology laboratory of Jackson Memorial Hospital, 110 sputum samples from 62 hospitalized patients with suspected AIDS were examined for Pneumocystis carinii. Sputum specimens were either expectorated spontaneously (most patients) or expectorated after the inhalation of small amounts of nebulized normal saline. Each sputum sample was cytocentrifuged onto two slides. One slide was stained with Gomori methenamine-silver (GMS) and the other with cresyl violet (CV). Among the 62 study patients, 18 were proven to have no histologic evidence of P carinii pneumonia. Of the remaining 44 patients, P carinii organisms were found by GMS stain in 14 (32%) and by CV stain in 18 (41%). Among those with a positive CV stain, the diagnosis was made on the first sputum specimen in 14 patients and on the second specimen in the remaining four patients. CV stain is at least as sensitive as GMS in detecting P carinii cysts in the sputum of AIDS patients with P carinii pneumonia, and its diagnostic sensitivity may exceed 40% under field conditions. Further, CV stain is much simpler to prepare than GMS and much simpler to interpret than Giemsa. It could be easily adapted for general use to expedite the diagnosis and treatment of P carinii pneumonia.

Carcinomatous meningitis from transitional cell carcinoma of the bladder: case report.

In the past decade, there has been an increasing awareness of central nervous system metastases as a frequent complication of some malignancies, particularly in lung, breast and hematologic cancers. However, the central nervous system remains an uncommon location for metastases from certain primary tumors including those from the genitourinary system. We report on a patient with transitional cell carcinoma of the bladder who was treated with combination chemotherapy, and during the course of his disease developed carcinomatous meningitis. We anticipate this unusual complication of bladder transitional cell carcinoma will be seen more frequently, especially in the light of available data from effective chemotherapeutic regimens. We report this patient to alert physicians to this complication and to consider using prophylactic measures in responding patients as is the case in other malignancies.