Aspiration biopsy of osseous metastasis of retroperitoneal paraganglioma. Report of a case with cytologic features and differential diagnostic considerations.

BACKGROUND: Paragangliomas are uncommon tumors, only 10% of which are malignant, as evidenced by metastatic disease. It is rare for paraganglioma to present with symptomatic osseous metastases. CASE: A retroperitoneal paraganglioma presented in a 52-year-old man as painful metastases in the rib and vertebrae. Fine needle aspiration (FNA) of a lumbar vertebral lesion showed cells arranged singly and in loose clusters with fragile, vacuolated or finely granular cytoplasm, marked anisonucleosis and mitoses. Rare zellballen-type structures and intranuclear inclusions were present. Immunohistochemical studies of a subsequent FNA core biopsy of the retroperitoneal mass showed strong immunoreactivity with chromogranin and negative staining for keratin; that was helpful in differentiating this tumor from others in the differential diagnosis. CONCLUSION: The cytologic diagnosis of paraganglioma is difficult as these tumors exhibit a plethora of features that overlap those of many other neoplasms. The diagnosis can be confirmed with appropriate immunohistochemical studies of corresponding core biopsies.

Should the cytologic diagnosis of "atypical squamous cells of undetermined significance" be qualified? An assessment including comparison between conventional and liquid-based technologies.

BACKGROUND: The diagnosis of atypical squamous cells of undetermined significance (ASCUS) remains an enigma for the treating physician, because it encompasses both benign, reactive, as well as preneoplastic and possibly neoplastic conditions. To address this problem, The Bethesda System recommends qualifying the ASCUS diagnosis. This study analyzes the difference in the follow-up results between the various groups of patients with an ASCUS diagnosis as outlined by the Criteria Committee: favor premalignant (ASCUS-P), favor reactive (ASCUS-R), and unqualified (ASCUS-C). The outcome, based on follow-up biopsies and/or cytologies, for both the conventional Papanicolaou smear (CS) and liquid-based (LB) methodologies is compared. METHODS: The CS and LB biopsies and/or cytologies included 590 patients and 137 patients, respectively, who had an initial diagnosis of ASCUS. The final outcome after subsequent biopsy and cytology within a 1-year period for each methodology was tabulated. Furthermore, the addition of qualifiers for each diagnosis was tabulated for both cytology and biopsy follow-up and compared between CS and LB technologies. RESULTS: For CS, 29 patients (8.6%) were found to have squamous intraepithelial lesions (SIL) on subsequent cytologic smears, and 176 patients (63.7%) had SIL on biopsy follow-up. For LB, these numbers were 17 patients (19.1%) and 56 patients (65.1%), respectively. Regardless of the qualification used in the initial CS biopsy or cytology, over 90% of the subsequent smears resulted in a benign diagnosis. Biopsy outcomes after CS diagnoses of ASCUS-P, ASCUS-R, and ASCUS-C showed SIL in 80%, 53%, and 66% of patients, respectively. For LB diagnoses, subsequent smears detected SIL in 33% of patients with a diagnosis of ASCUS-P, 22% of patients with a diagnosis of ASCUS-R, and 12% of patients with a diagnosis of ASCUS-C. Biopsy outcomes after LB diagnoses of ASCUS-P, ASCUS-R, and ASCUS-C showed SIL in 68%, 64%, and 66% of patients, respectively. CONCLUSIONS: There appears to be no statistically valid benefit from a clinical point of view in qualifying an ASCUS interpretation by either CS or LB, except for CS evaluation of patients with a diagnosis of ASCUS-P.

Quality assurance and risk reduction guidelines.

Cervical cancer continues to be a major cause of death in women worldwide. The major problem facing most women is the unavailability of screening Pap tests in poor and underdeveloped countries. While rates of cancer deaths have decreased 60-80% in developed countries since the Pap test became available, the accuracy of Paps was challenged recently. In order to instill public confidence and promote optimal patient care, measures to improve the quality of the entire screening process should be undertaken. Continuous quality improvement processes are more appropriate than traditional quality assurance monitors. Although no standards can be defined that are applicable to all laboratory settings and nations, this document provides current views on universal quality procedures and risk reduction. Procedure/policy manuals, workload assessment, hierarchic/peer review, discrepancy analysis, rescreening studies and cytohistologic correlation are examples of universally applicable quality tools. The variability in practices in different parts of the world is also discussed.

Angiosarcoma at unusual sites. A report of two cases with aspiration cytology and diagnostic pitfalls.

BACKGROUND: Angiosarcomas are uncommon soft tissue neoplasms with a predilection for skin and superficial soft tissues. CASES: Two cases of angiosarcoma occurred at unusual sites, the parotid gland and lung. The parotid lesion was characterized by malignant cells present singly, in loose groups, in tight three-dimensional aggregates and in acinar formation initially misinterpreted as an adenocarcinoma. The lung mass showed malignant cells in association with vascular endothelium, suggestive of angiosarcoma. Both cases were negative for Ulex europaeus and Factor VIII-related protein but demonstrated strong immunopositivity for CD31, a highly specific endothelial marker. CONCLUSION: In the absence of vasoformative structures, important diagnostic pitfalls are pseudovascular adenoid squamous cell carcinoma, poorly differentiated adenocarcinoma, melanoma and lymphoma. Immunocytochemical studies and clinical history are essential to the correct diagnosis.

Heterotopic calcification in abdominal wounds.

BACKGROUND: Heterotopic bone formation in abdominal incisions is a recognized but uncommon sequela of abdominal surgery. The condition of heterotopic bone formation in the abdominal scar may not only cause physical and/or emotional discomfort for the patient but also mimic a retained foreign body or recurrence of a malignant condition. All cases of two surgeons representing a wide variety of general and thoracic surgery were reviewed, and three primary cases and one recurrent case of heterotopic bone formation in an abdominal wound were identified. These cases are compared with the cases available in the English literature to enhance the recognition, appropriate diagnosis, and treatment options available for the patient with this unusual condition. METHODS: All cases for two surgeons representing a variety of general and thoracic surgery were reviewed. Three patients with painful heterotopic calcification of an abdominal incision requiring excision were identified. One patient had undergone an upper midline laparotomy for pancreatitis and the other two had undergone median sternotomy for cardiac surgery. One of these patients developed a painful recurrence of upper linea alba calcification. All patients were male and ranged in age from 51 to 74 years. Primary heterotopic calcification of the upper linea alba occurred between 2 and 4 months for all patients. All cases were treated with excision and primary tissue closure. The case of recurrent calcification occurred 1 1/2 months after primary closure, and was treated with re-excision and 1,200 centirads of postoperative radiotherapy to the incision area over 3 days, starting on postoperative day 1. The 2 cases of primary heterotopic calcification successfully treated with the initial excision have been followed for 2 and 6 years respectively without recurrence. The case of recurrent heterotopic calcification treated with re-excision and postoperative radiotherapy has been followed for 10 months without recurrence.

Glandular lesions of the cervix. Validity of cytologic criteria used to differentiate reactive changes, glandular intraepithelial lesions and adenocarcinoma.

OBJECTIVE: To determine the validity and reproducibility of various cytologic criteria as discriminators between different glandular lesions of the cervix. STUDY DESIGN: Seventy-three cervicovaginal smears with glandular lesions and a documented histologic and/ or clinical correlation were studied. The lesions included reactive changes, low grade glandular intraepithelial lesion (LGIL) (encompassing endocervical glandular dysplasia), high grade glandular intraepithelial lesion (HGIL) (encompassing adenocarcinoma in situ) and invasive adenocarcinoma (IA). Twenty-three cytologic criteria were used to evaluate the smears, and the results were scored and statistically analyzed. RESULTS: Reactive lesions consistently showed well-defined cell borders, normal nuclear/cytoplasmic (N/C) ratio, minimal or absent nuclear overlapping, round to oval nuclei with fine chromatin and prominent nucleoli. HGIL (adenocarcinoma in situ) showed feathered edges, rosettes, cell strips, increased N/C ratio, elongated nuclei, marked nuclear overlapping and nuclei with hyperchromatic, coarse chromatin. IA shared features with HGIL but had a greater tendency to show a dirty background, single cells, mitotic figures, nuclear pleomorphism and large nucleoli. Logistic regression studies indicated that the presence of mitotic figures, a dirty background and single cells increases the odds ratio for predicting invasion. LGIL showed features similar to those of high grade lesions, but the changes were more subtle. These lesions were also less cellular and less likely to show cell strips, feathered edges and rosettes. Similar to HGIL and IA, LGIL showed nuclear overlapping, increased N/C ratio, oval to elongated nuclei and nuclear hyperchromasia. CONCLUSION: There is overlap between the cytologic criteria for the various glandular lesions of the cervix. However, some of these criteria can consistently distinguish clinically significant lesions from reactive benign changes seen in the glandular epithelium.

Ber-EP4 for differentiating adenocarcinoma from reactive and neoplastic mesothelial cells in serous effusions. Comparison with carcinoembryonic antigen, B72.3 and Leu-M1.

OBJECTIVE: To evaluate the efficacy of Ber-EP4 in distinguishing epithelial cells from mesothelial cells in routine cytologic preparations. STUDY DESIGN: Paraffin-embedded cell blocks of serous effusions from 32 patients (11 metastatic adenocarcinomas, 16 reactive mesothelial proliferations and 5 malignant mesotheliomas) were immunostained with Ber-EP4. For comparison, cell block preparations of adenocarcinomas and mesotheliomas were also immunostained with the most commonly applied markers of adenocarcinoma: carcinoembryonic antigen (CEA), B72.3 and Leu-M1. In addition, cytocentrifuge preparations of 14 reactive effusions and 2 metastatic adenocarcinomas were stained prospectively with Ber-EP4. RESULTS: All adenocarcinomas showed intense membrane staining, while all mesothelial proliferations, both benign and malignant, were negative. The Ber-EP4-positive immunostaining was remarkably clean, with very minimal nonspecific staining. CEA stained 11/11 adenocarcinomas, B72.3 stained 10/11, and Leu-M1 stained 8/11; mesotheliomas were negative with all three antibodies. CONCLUSION: Ber-EP4 is at least as useful as CEA, B72.3 and Leu-M1 in the diagnosis of serous effusions. It has the advantage of high sensitivity and ease of interpretation because of the high percentage of tumor cells stained, characteristic membranous staining and lack of cross-reaction with background inflammatory cells.

"Osteoclastic" giant cell carcinoma of the pancreas. Report of a case with aspiration cytology.

BACKGROUND: Osteoclastic giant cell carcinoma (OGC) is an uncommon variant of ductal carcinoma of the pancreas. It is important to differentiate this variant from other giant cell pancreatic lesions, particularly the more aggressive pleomorphic giant cell carcinoma. CASE: Aspiration cytology was performed in a case of OGC. Aspirates of OGC demonstrated three populations of discohesive cells: (1) large, bizarre, pleomorphic malignant giant cells with high nuclear/cytoplasmic ratios, irregular nuclear membranes and coarse chromatin; (2) spindle or small mononucleate cells; and (3) bland, osteoclastlike epithelial giant cells with multiple small, round, central nuclei and prominent nucleoli. CONCLUSION: Multinucleate giant cells can be seen in pancreatic abscesses, fat necrosis, pseudocysts, tuberculosis, sarcoidosis and fungal infections. When the cells are associated with malignant epithelial cells, the differential diagnosis includes metastatic carcinoma, malignant melanoma, Hodgkin's disease, large cel anaplastic lymphoma, trophoblastic tumor, epithelioid sarcoma, malignant fibrous histiocytoma, angiosarcoma and rhabdomyosarcoma. Immunohistochemical stains, such as vimentin, S-100, leukocyte common antigen, human chorionic gonadotropin, Factor VII Ag, actin and desmin play an important role in differentiating between these lesions.

Cytology of gastrointestinal histoplasmosis. A report of two cases with differential diagnosis and diagnostic pitfalls.

BACKGROUND: Gastrointestinal (GI) histoplasmosis is a rare manifestation of Histoplasma capsulatum (HC) infection. There are no reports of its cytologic diagnosis in the literature. CASES: A search of the cytology and surgical pathology files of the Methodist Hospital uncovered two cases of GI histoplasmosis and histiocytes within cytologic specimens. Papanicolaou-stained endoscopic brushings of an obstructing, apple-core, right colonic mass in a 58-year-old, heterosexual male revealed numerous vacuolated single cells interpreted as suspicious for signet ring cell carcinoma. The resected colon showed granulomatous inflammation with numerous histiocytes containing pale, oval yeasts of HC. The patient was subsequently found to be human immunodeficiency (HIV) positive; this was his first manifestation of the acquired immunodeficiency syndrome. The second patient was a 69-year-old, HIV-negative male with a fungating anal mass suspicious for squamous cell carcinoma. Direct smears showed oval histiocytes with intracellular yeasts of HC. CONCLUSION: Accurate diagnosis is crucial to patient management and therapy. Careful attention to the nuclear and cytoplasmic details of histiocytes and histiocytelike cells is important to avoid interpretive errors. Diagnostic pitfalls include signet ring cell adenocarcinoma, lymphoma, melanoma, goblet cell carcinoid, malakoplakia and such infections as mycobacteria, Entamoeba histolytica and Calymmatobacterium granulomatis. Ancillary studies, such as microbiologic cultures and immunohistochemical and histochemical staining, can be performed in the appropriate clinical setting.

GLUT1 expression in human breast carcinoma: correlation with known prognostic markers.

BACKGROUND: Breast cancers have been shown to have increased glucose uptake and utilization, and to express the facilitative glucose transporter Glut1. The aim of this study was to determine the biological significance of Glut1 expression in breast cancer. METHODS: Paraffin sections of 118 breast cancers were immunostained with antibody to Glut1. The percent of Glut1-positive cancer cells in each tumor was correlated with known prognostic markers, and with patient outcome. RESULTS: Glut1 was expressed in 42% of the tumors. Glut1 immunoreactivity correlated positively with the proliferative activity as determined by Ki-67 immunostaining, and with the total histologic score, and showed negative correlation with bcl-2 immunostaining. There was no correlation between the percent of Glut1-immunoreactive cancer cells and estrogen receptor status, tumor size, or lymph node status. CONCLUSIONS: 1) Glut1 expression is increased in breast cancers with higher grade and proliferative activity, and 2) glucose transport in the majority of breast cancers may be mediated by a glucose transporters other than Glut1.

p53 protein accumulation in tumors of the ampulla of Vater.

BACKGROUND: Accurate preoperative diagnosis of tumors of the ampulla of Vater is difficult because ampullary biopsies have a high false-negative rate. Recently, it has been suggested that p53 mutations in tumors of the ampulla of Vater are associated with the transformation of adenomas and low grade carcinomas to high grade carcinomas. The purpose of this study was to determine the extent of p53 protein accumulation in tumors of the ampulla of Vater, and to determine whether p53 accumulation can be detected in false-negative biopsies. METHODS: Using a monoclonal anti-p53 antibody, sections of 4 normal ampullas, 5 adenomas, 17 carcinomas, and 9 initial biopsies of 9 of the tumors of the ampulla of Vater that had no morphologic evidence of carcinoma were immunostained. RESULTS: None of the 4 normal ampullas (0%), 2 of 5 adenomas (40%), and 16 of 17 carcinomas (94%) were positive for p53. This p53 positivity was present through all stages of ampullary carcinoma. Of the nine initial biopsies negative for carcinoma, seven were positive for p53 and, of these, six (86%) were found to be carcinomas upon resection. CONCLUSIONS: 1) The molecular events leading to p53 accumulation in tumors of the ampulla of Vater occur early in the neoplastic process. 2) Tumors of the ampulla of Vater with biopsies negative for malignancy but positive for p53 are very likely to be carcinomas.

A histologic study of soft-tissue reactions to spinal implants.

OBJECTIVES: The biologic reactions to orthopedic spinal implants were determined. METHODS: Biopsies of soft tissue immediately adjacent to spinal implants were done in 36 consecutive patients undergoing elective lumbar spinal hardware removal and was studied histologically. RESULTS: A fibrous tissue matrix was noted in all specimens. In 11 of 36 specimens, a discrete layer of cells with epithelial characteristics was noted on the surface immediately opposed to the metal implant. Results of immunohistochemical staining were negative using antibodies to markers, which suggests that these unique cell layers are probably of histiocytic origin. Black amorphous metallic debris was seen in nine of the specimens. In seven of these specimens, this material was associated with an inflammatory foreign-body reaction. Refractile non-biorefringent crystalline bodies were noted in five specimens. These crystalline deposits provoked a local foreign-body reaction in all cases. CONCLUSION: The role of soft-tissue inflammatory reactions in the production of clinical symptoms of pain is discussed.

Alpha-mannosidosis. Report of a case with morphologic, cytologic and immunohistochemical considerations.

We report the histopathologic features of the knee bone and synovium and the cytologic features of the synovial fluid from a patient with alpha-mannosidosis. The synovium showed marked papillary hyperplasia with infiltration of foamy histiocytes containing periodic acid-Schiff-positive, diastase-resistant material. Severe degenerative changes were seen in the knee bone. The synovial fluid showed increased numbers of macrophages containing periodic acid-Schiff-positive, diastase-resistant material. The differential diagnostic considerations in the synovial fluid are also discussed.

Ploidy studies by image analysis on fine needle aspirates of the breast.

Quantitative DNA analysis was performed on preoperative fine needle aspirates of 12 breast cancers and 1 benign lesion using the Cell Analysis Systems (CAS) Model 200 image analysis system. The smears were prepared on CAS slides, routinely processed for Papanicolaou staining, and then destained and restained with Feulgen stain after cytologic evaluation. Four cases were DNA diploid, 3 were tetraploid, 1 was diploid/tetraploid, and 5 were aneuploid. When compared to analysis of samples from the resected tumor, both DNA index and S-phase fraction were constant.

A histologic study of lumbar pseudarthrosis.

Biopsy specimens were obtained from 35 consecutive patients undergoing pseudarthrosis repair after failed posterior spinal fusions. Biopsy specimens were obtained when possible from the fusion mass, from areas of motion, and from the lumbar facet remnant where identifiable. Tissue found between adjacent bony segments was noted to contain predominantly fibrous tissue often accompanied by signs of local fibrocartilaginous metaplasia. In addition, small fragments of impacted bone, sometimes seen to be undergoing active resorption, also were noted frequently in these areas. The bone adjacent to the areas of motion was sclerotic and poorly organized, containing a mixture of woven and lamellar bone. Interestingly, multiple microtrabecular fracture with appositional new bone formation was a frequently seen feature. All facet joint biopsies were noted to have evidence of degenerative disease. Both cartilage fissuring and significant chondrocyte cloning were noted. Subchondral bony sclerosis was also a consistent feature.

Papillary fibroelastoma. A right atrial presentation.

Papillary fibroelastoma is a rare cardiac tumor arising most frequently from valvular endocardium. These tumors are clinically important because of their tendency to embolize. Emphasis is therefore placed on early detection and surgical excision. We describe a case of a papillary fibroelastoma arising from the right atrium. To our knowledge, only 2 such cases have been reported in the English literature. Our case illustrates the discovery of a rare, but potentially fatal cardiac tumor, successfully removed by surgery.

Gynecologic cytology. Practical considerations and limitations.

Diagnostic problems arise as a result of overlap of cytologic criteria of some squamous and glandular lesions of the female genital tract, lack of experience, or an overzealous attempt to interpret some features. This article emphasizes the role and limitations of cytology in the diagnosis of neoplasia and preneoplasia of squamous and glandular elements of the uterus. Sampling techniques greatly influence the pathologist's ability to interpret the material. The classifications and cytologic features of preneoplastic and neoplastic squamous and glandular epithelia, including the new Bethesda System for reporting, are reviewed. Problems in interpretation, particularly of nondysplastic conditions that mimic true neoplasia, and reasons for false-negative and false-positive results are discussed.

Estrogen and progesterone receptors in bronchogenic carcinoma.

Although the lung is not usually considered a major target organ of sex hormones, epidemiological observations, studies of pulmonary neoplasms in laboratory animals, and investigations of carcinomas derived from other "nontarget" organs suggest that sex hormones may have a role in the pathogenesis of bronchogenic carcinoma. To confirm that estrogen (ER) and progesterone receptors are present in human lung cancers, 19 resected lung cancers were examined for receptors using a prelabeled sucrose gradient method. Three squamous cell carcinomas were positive for ER (greater than 6.9 fmol/mg cytosol protein). Three squamous cell carcinomas, two adenocarcinomas, and one small cell carcinoma were positive for progesterone receptors (greater than 6.9 fmol/mg cytosol protein). One tumor, a squamous cell carcinoma arising in a woman who smoked, had an ER level of 301 fmol/mg, a highly positive level even for breast cancers. These observations may provide a basis for adjuvant hormonal therapy in selected lung cancer patients.

Thymic carcinoma. A clinicopathologic study of 13 cases.

Thymic carcinoma (TCA) is a thymic epithelial neoplasm with obvious cytologic atypia. We studied 13 cases of TCA by light microscopy, immunohistochemistry, and electron microscopy and correlated the findings with clinical features. The patients' mean age was 54.2 years (range 30-74); the male/female ratio was 7/6. Twelve of the 13 patients presented with signs and symptoms caused by compression of mediastinal organs; the other patient was asymptomatic. Paraneoplastic syndromes were never seen. At thoracotomy, 11 tumors invaded or adhered to surrounding structures; the other two were encapsulated. The histologic types include squamous carcinoma including the lymphoepithelioma-like subtype (seven cases), small cell carcinoma (four cases), clear cell carcinoma (one case), and adenosquamous carcinoma (one case). Positive immunoperoxidase studies were as follows: keratin (13 cases), epithelial membrane antigen (EMA) (13 cases), leukocyte common antigen (none), carcinoembryonic antigen (CEA) (five cases), B72.3 (seven cases), Leu 7 (two cases), human placental alkaline phosphatase (none), vimentin (none), and chromogranin (one case). This profile is similar to those of normal thymus and thymoma except for the absence of CEA, B72.3, EMA in normal thymus, and the absence of CEA and B72.3 in thymoma. Electron-microscopic studies performed on eight cases showed glandular and squamous differentiation in one adenosquamous carcinoma, squamous differentiation in five squamous carcinomas, and neuroendocrine differentiation in one small-cell carcinoma. Nine patients died (three due to postoperative complications and six due to recurrences or metastasis at 3-36 months). Four patients (all with squamous carcinoma) were alive without disease at 2-60 months. The clinical and pathologic features were comparable with those of approximately 62 other cases of TCA previously reported. There are a number of well-defined histologic types of TCA that allow the pathologist to make a differential diagnosis of TCA from tumors extending or metastatic to thymus or other primary mediastinal tumors. Although neither asymptomatic presentation nor encapsulation improves the poor prognosis of TCA, the squamous carcinoma subtype is associated with a better outcome than the other subtypes. Based on the electronmicroscopic and immunohistochemical findings, the presence of normal thymic tissue at the periphery of several tumors, and the observation that several TCA arose from preexisting thymomas or thymic cysts, we conclude that TCA is derived from thymic epithelium.