[Inflammatory Myofibroblastic Tumor Misdiagnosed as Intrahepatic Cholangiocarcinoma].

An inflammatory myofibroblastic tumor (IMT) is a rare tumor that is currently classified as an intermediate cancer according to the World Health Organization classification system. The pathophysiology of its occurrence is still unknown. Imaging tests, such as CT or MRI, can be helpful in diagnosis, but the final diagnosis is confirmed by a pathological examination through a biopsy and immunohistochemistry stain. The patient, in this case, presented an asymptomatic intrahepatic mass discovered incidentally on an imaging examination. Initially, intrahepatic cholangiocarcinoma was suspected, but she was finally diagnosed with IMT through a histological examination after a liver resection.

Effect of the Paris system for reporting urinary cytology with histologic follow-up.

BACKGROUND: The Paris system (TPS) for Reporting Urinary Cytology provides a standardized reporting system whose main focus is the diagnosis of high-grade urothelial carcinoma (HGUC). We conducted a study to see the impact of The Paris System on our cytologic diagnoses with associated histology. MATERIALS AND METHODS: We reviewed our pathology database regarding urinary specimens in the year before implementation of The Paris System and the year after. We gathered the data regarding cytologic diagnosis and concurrent/subsequent histology. RESULTS: Over a 1-year period from 2016-2017, 486 urine cytology specimens were identified before implementation of The Paris System and diagnosed as follows: 83% benign/negative, 10% atypical, 2% suspicious, 5% HGUC, 0.2% low grade urothelial neoplasm (LGUN), and 0.2% unsatisfactory. Over a next 1-year period from 2017 to 2018, 602 specimens used TPS and diagnosed as follows: 85% negative for HGUC, 6% atypical, 3% suspicious, 4% HGUC, 0.17% LGUN, and 2% unsatisfactory. Although, not listed as a standardized category in The Paris System, our institution used "Negative for high-grade, cannot rule out low-grade urothelial neoplasm (NHL)" as a subcategory of Negative for HGUC. 4% of the cases fell into this category. Focusing on the Atypical category before TPS, histology was available in 15/49 (31%) cases. Of these, 40% had HGUC. Regarding the Atypical category after TPS, histology was available in 21/36 (58%) cases. Of these, 52% were HGUC. For the NHL category, concurrent histology was available in 13/26 (50%) cases. Of these, 67% were low grade urothelial neoplasms. CONCLUSION: Our study showed that TPS lowered the rate of Atypical from 10% to 6%. After the implementation of TPS, Atypical corresponded to a higher rate of high-grade urothelial carcinoma. Also, the NHL subcategory had a high positive predictive value for diagnosing low grade urothelial neoplasms.

A case of metastatic rectal adenocarcinoma diagnosed by thyroid cytology.

Fine-needle aspiration (FNA) cytology of the thyroid gland has been widely used for the evaluation of thyroid nodules. Most of the nodules are primary thyroid lesions. However, up to 4% of thyroid FNA may harbor a metastatic neoplasm. The metastases are most commonly from lung, kidney, breast, and skin. Metastatic colorectal cancers are also seen in thyroid but less common. Here we report the cytologic features, differential diagnosis and clinical implications of a metastatic rectal adenocarcinoma to the thyroid gland diagnosed by FNA.

Cytologic features of vaping-induced lung injury: A case report.

Vaping-induced lung injury is a recently recognized phenomenon owing to the rising popularity of e-cigarette use. A cluster of cases of varying severity, including six deaths, was recently reported in the United States by the Centers for Disease Control. The objective of this report is to highlight the cytologic features suggestive of vaping-induced lung injury. A 20-year-old previously healthy man presented with a 7-day history of progressively worsening respiratory symptoms including dyspnea on exertion, cough, and fever, with no improvement after initiating a course of antibiotics. No relevant travel or occupational history was reported, but patient endorsed daily use of e-cigarette with a fluid containing both tetrahydrocannabinol and nicotine. Radiographic studies demonstrated scattered areas of interlobular septal thickening and diffuse ground-glass opacities in both lungs. Laboratory tests for HIV and influenza were negative. Bronchoscopy and bronchoalveolar lavage were performed, with cytologic study showing clusters of benign bronchial cells and an increase in lipid-laden macrophages by Oil Red O stain. Patient was placed on steroid and steadily improved for the next 2 days. He was discharged on a steroid taper and follow-up with respiratory clinic. Case reports and series have shown a variety of lung injury patterns in previously healthy patients who are frequent users of e-cigarettes and among them features suggestive of lipoid pneumonia with increased lipid-laden macrophages. The clinical utility of this finding is still unclear.

Cytologic and clinical features of NIFTP: Can we diagnose based on preoperative fine-needle aspiration.

BACKGROUND: Noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) is considered an indolent neoplasm of the thyroid. Currently, this entity presents a diagnostic challenge on preoperative fine-needle aspiration (FNA) cytology. METHODS: Cases of NIFTP and noninvasive encapsulated follicular variant of papillary thyroid carcinoma from January 1994 to August 2018 were retrieved from our institution's pathology databases, and their clinical and cytopathologic features were reviewed. RESULTS: A total of 45 patients with NIFTP were identified. Thirty-nine of 45 patients had presurgical thyroid FNAs, 27 of which showed abnormal cytology (27/39). NIFTPs were most often classified in the indeterminate diagnostic categories on presurgical FNAs (78%), including suspicious for follicular neoplasm (8/27), atypia of undetermined significance (8/27) and suspicious for malignancy (5/27). Six patients had a cytologic diagnosis of papillary thyroid carcinoma (6/27) on thyroid FNAs. Fourteen out of 27 cases with abnormal FNAs had in-house cytology available for review. The most frequent cytologic features observed in NIFTPs included architectural abnormalities, such as crowded clusters (13/14), nuclear overlapping (13/14), predominance or presence of individual microfollicles (11/14), and abundant to scattered isolated cells (10/14). The papillary-like nuclear features observed included nuclear enlargement (14/14), eccentric nucleoli (13/14), nuclear membrane irregularity (12/14), pale chromatin (12/14), nuclear grooves (10/14), and elongated nuclear contour (8/14). CONCLUSIONS: The NIFTPs were most frequently categorized as atypia of undetermined significance and suspicious for follicular neoplasm on cytology. Recognition of the architectural and nuclear features of NIFTP can be helpful in distinguishing NIFTPs from other entities, such as papillary thyroid carcinoma and follicular neoplasms.

Neuroendocrine carcinoma of the colon presenting as acute meningitis.

BACKGROUND: Neuroendocrine tumors represent an expansive group of neoplasms that share an etiology of epithelial origin with neuroendocrine differentiation. Poorly-differentiated neuroendocrine carcinomas behave similarly to their aggressive pulmonary counterpart, small cell lung carcinoma. Most patients with gastroenteropancreatic neuroendocrine tumors present with symptoms of metastasis, most commonly to the liver. There have been no case reports, to our knowledge, until now that demonstrate metastasis to the central nervous system. CASE PRESENTATION: A 72-year-old male with poorly-differentiated stage IIIB neuroendocrine carcinoma of the colon presented with acute altered mental status and right facial droop. Head CT was negative for an acute hemorrhagic process without evidence of suspicious lesions. Several days later, the patient developed fever and neck stiffness suspicious for bacterial meningitis. A lumbar puncture procedure was performed. Cytology of the CSF demonstrated metastatic disease to the central nervous system and the final diagnosis of carcinomatous meningitis secondary to metastatic neuroendocrine carcinoma of the colon was made. CONCLUSIONS: High-grade gastroenteropancreatic neuroendocrine carcinomas most commonly metastasize to the liver, which often corresponds with the patient's initial presentation. When neuroendocrine tumors do metastasize to the central nervous system, the primaries are most commonly of pulmonary origin. When meningeal metastasis does occur, it commonly presents as neurologic deficits or cerebrovascular events, rarely does meningeal metastasis mimic bacterial meningitis with symptoms of fever, photophobia and meningismus. As neuroendocrine carcinomas have been increasing in incidence over the past several decades, it is important to consider varying metastatic presentations when working up a patient with a diagnosis of neuroendocrine tumor.

Reactive histiocytic proliferation in the pleural fluid mimicking metastatic signet ring adenocarcinoma.

Reactive nodular and diffuse histiocytic proliferations of mesothelial and non-mesothelial lined sites have been sporadically reported in the literature. However, there is no cytologic literature describing this process. We report a case of reactive histiocytic proliferation mimicking a metastatic signet ring adenocarcinoma in pleural fluid from a 33-year-old white male. Ancillary studies such as immunohistochemistry should be used to elucidate the cell of origin and avoid diagnostic errors.

Utility of core biopsy with concurrent ROSE FNA in the diagnosis of pancreatic tumor-does the biopsy add any diagnostic benefit?

BACKGROUND: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endoscopic ultrasound-guided core-needle biopsy (EUS-CNB) are widely used for diagnosis of pancreatic tumors. The aim of our study was to compare the diagnostic performance of ROSE EUS-FNA and EUS-CNB for diagnosis of pancreatic malignancy during the same EUS. METHODS: Patients who underwent both FNA and CNB during the same EUS for pancreatic solid lesion were reviewed retrospectively. Sample adequacy, diagnostic yield (defined as percentage of definitive diagnosis), sensitivity and specificity for malignancy were compared between FNA and CNB. RESULTS: A total of 48 patients with solid pancreatic lesions were evaluated. The proportions of adequate samples were 48/48 (100%) for FNA and 45/48 (93.7%) for core biopsy (P = .24). The diagnostic yield was 42/48 (87.5%) and 33/48 (68.7%) for FNA and CNB respectively (P = .046). The incremental increase in diagnostic yield by combining both methods was 2/48 (4%). The diagnostic yield for malignancy was 30/32 (93.7%) for FNA and 23/32 (71.8%) for CNB (P = .043). The sensitivity for the diagnosis of malignancy for FNA and CNB were 90.6% and 69%, respectively (P = .045). The specificity was 100% for both methods. The sensitivity for diagnosing malignancy increased to 93.8% when the two methods were combined. The difference in diagnostic yield was not associated with lesion size or location. CONCLUSION: EUS-guided FNA is a superior method of assessing solid pancreatic lesion and pancreatic malignancy with better diagnostic yield and higher sensitivity than EUS-CNB.

Follow-up of indeterminate cytologic diagnoses of solid pancreatic lesions: atypia versus suspicious (one institution's experience).

INTRODUCTION: A comparison of the long-term risk of malignancy between indeterminate cytological diagnoses, namely, atypical versus suspicious for malignancy, from endoscopic ultrasound-guided (EUS) fine-needle aspiration (FNA) of a pancreatic mass has not been well characterized. The primary aim of this study was to compare the risk of malignancy between patients with such indeterminate diagnoses. Secondarily, we investigated whether serologic markers serve as predictors of risk of malignancy in the setting of indeterminate cytological diagnoses. MATERIALS AND METHODS: We reviewed 484 cases of EUS-FNA on solid pancreatic lesions, performed at a single academic tertiary care center from 2004 to 2017. Patients with solid pancreas mass lesions who had atypical or suspicious final cytology were identified for further clinical outcome analysis. RESULTS: Of the 484 patients with pancreas mass lesions, 53 (11%) were given an indeterminate final cytologic diagnosis, with 28 atypical and 25 suspicious for malignancy. Follow-up was completed for 22 and 20 patients from atypical and suspicious diagnoses, respectively. Of patients with follow-up, 15 (68%) and 18 (90%) had subsequent diagnoses of malignancy from atypical and suspicious groups, respectively. There was no statistical difference in predicting risk of malignancy between the two groups (P = 0.24). Serologic markers were available in 29 of 42 patients with follow-up. Serologic markers were elevated in 21 of 29 patients and all were subsequently diagnosed with malignancy. Elevated serologic markers correlated with future risk of malignancy (P = 0.0026). CONCLUSION: The risk of subsequent malignancy is high for both atypical and suspicious pancreatic solid lesions but there exists no statistical difference between the two. Combined serologic markers with indeterminate cytology proved to be a good predictor of malignancy.

Schistosoma haematobium: A Delayed Cause of Hematuria.

A 22-year-old African American man with recurrent episodes of gross hematuria for 6 months presented to the clinic for evaluation. A thorough history revealed that the patient emigrated from Mozambique to the United States 12 years ago. Urine culture was negative for a urinary tract infection. Cystoscopy revealed 4 lesions in the bladder. Biopsy of the bladder lesion revealed severe cystitis and Schistosoma haematobium. The patient later confirmed that he used to swim in rivers and streams back in Africa. He completed a course of praziquantel and his gross hematuria resolved.

Endobronchial Metastasis from Extrapulmonary Neoplasms: Analysis of Clinicopathologic Features and Cytological Evaluation by Bronchial Brushing.

PURPOSE: Bronchial brushings (BB) commonly aid in the diagnosis of primary lung cancer. However, the utility of this method in diagnosing endobronchial metastases (EBM) from extrapulmonic malignancies has not been thoroughly evaluated. The purpose of this study is to evaluate the sensitivity of BB in diagnosing EBM. METHODS: An institutional database was queried for all patients with cytologically or histologically confirmed extrapulmonary EBM identified by endobronchial biopsy between 1978 and 2013. Data were collected on patient demographics, histologic and cytologic diagnoses, time from primary malignancy to identification of EBM, and location of EBM. The sensitivity of BB for the diagnosis of EBM and the clinicopathologic features of extrapulmonary EBM were assessed. RESULTS: Fifty-six patients (33 females, 23 males; mean age 53 years) were identified with EBM. Diagnoses included lymphoma (21), breast adenocarcinoma (11), colonic adenocarcinoma (7), melanoma (6), renal cell carcinoma (RCC, 5), embryonal carcinoma (2), and 1 case each of tonsillar squamous cell carcinoma, thymic carcinoma, leiomyosarcoma, and sarcoma, not otherwise specified. The sensitivity of BB for identifying EBM was 85% overall and 94% for non-hematologic malignancies. The mean interval between primary diagnosis and EBM was 59 months (range 0-264 months). Excluding ten patients who had EBM at their initial presentation, lymphoma had the shortest (10 months) and RCC had the longest (264 months) mean interval between primary diagnosis and EBM. The mean time between EBM identification and death was 22.4 months (n = 24). CONCLUSION: Bronchial brushing is a sensitive technique for diagnosing non-hematologic extrapulmonic endobronchial metastases.

Metastatic Signet-Ring Cell Carcinoma of the Bladder in Cerebrospinal Fluid.

Primary bladder signet-ring cell carcinoma (SRCC) is extremely rare and associated with an aggressive course. To our knowledge, we describe the first metastatic bladder SRCC identified in cerebrospinal fluid (CSF). A 68-year-old male with 1 year history of primary bladder SRCC with spinal metastasis presented with multiple falls and loss of consciousness. Brain imaging showed high signal in the frontoparietal sulci and superior cerebellum. CSF analysis was significant for increased leukocytes with monocyte predominance while protein and glucose values were within normal range. There was a hypercellular population of pleomorphic tumor cells with signet-ring morphology, similar to those seen in his diagnostic bladder biopsies. The signet-ring cells were positive for cytokeratin 7 and 20 and negative for CDX-2 and prostate-specific antigen. The patient's clinical condition rapidly deteriorated and he died less than a week after presentation. At autopsy, brain sections revealed signet ring cells in the meninges overlying the cerebrum, cerebellum, brainstem, spinal cord, and pituitary with superficial invasion of the brain parenchyma. No brain parenchymal lesions were present. This case illustrates a unique complication of primary bladder SRCC. Diagn. Cytopathol. 2017;45:73-76. © 2016 Wiley Periodicals, Inc.

Cytomorphology and Clinicopathologic Correlation of the Recurrent and Metastatic Adult Granulosa Cell Tumor of the Ovary: A Retrospective Review.

Granulosa cell tumors (GCT) of the ovary are low grade tumor with a potential ability of late pelvic recurrences and distant metastases. However, there is sparse literature on the cytopathologic features of metastatic granulosa cell tumors (MGCT). Between 2000 and 2014, eight cases of MGCT were diagnosed by FNA. Clinical, cytologic, and histopathologic features were reviewed. The age ranged from 34 to 84 years. Metastases were found in abdominal wall (4 cases), pelvic mass (1 case), liver (2 cases), and lung (1 case). The time to metastasis ranged from 1 to 14 years. All cases were hypercellular, with both large and small overlapping cell clusters and individual cells. The cytologic features included: naked nuclei (8/8 cases), Call-Exner bodies (2/8 cases), and prominent metachromatic stroma (3/8 cases). Moderate cytoplasm (4/8 cases) to scant delicate cytoplasm (4/8 cases) was seen. Cytoplasmic vacuoles were also noted (6/8 cases). N/C ratios were high although lower than small round cell tumors like lymphoma. Prominent, central nucleoli were also present (6/8 cases) as well as nuclear grooves (2/8 cases). Cell block was available in 3/8 cases and all were positive for inhibin immunostain. Histologic examination of the metastatic tissue confirmed MGCT. The important cytologic features of GCT like uniformity of tumor cells, nuclear grooves and Call-Exner bodies are occasionally present in MGCT. Prominent nucleoli and many naked nuclei were frequent. Therefore, the accurate interpretation of cytologic findings of MGCT requires cytohistologic correlation and inhibin positivity to avoid unnecessary surgical interventions for diagnostic purposes. The possibility of late recurrence of GCT should be kept in mind. Diagn. Cytopathol. 2016;44:1058-1063. © 2016 Wiley Periodicals, Inc.

Cytomorphology, clinicopathologic, and cytogenetics correlation of myelomatous effusion of serous cavities: A retrospective review.

BACKGROUND: Myelomatous effusions (ME) of the serous cavities are rare. Identification of the atypical plasma cells in the body fluids may be critical for prognostic considerations. METHODS: We retrospectively reviewed clinicopathologic findings of 21 serous effusion specimens from 13 cases of ME including 10 pleural, two concurrent pleural and pericardial, and one peritoneal from 1994 to 2014. RESULT: All 13 patients had bone marrow biopsy-proven plasma cell myeloma (PCM), including one plasmablastic-variant, one anaplastic-variant and one plasma cell leukemia. The time between the bone marrow diagnoses to serous cavity involvement ranged from 43 days to 9 years (mean 2.6 years, median 1.8 years). Monoclonal protein types showed predominant IgA subtypes (50%) including IgA-kappa (2), IgA-lambda (3), IgG-kappa (2), IgG-lambda (1) free kappa chain (1) and free lambda chain (1) and three unknown. All 13 patients died of disease (median survival 32 days). Concurrent imaging studies showed evidence of adjacent local disease. Cytology of the serous fluids revealed abundant plasma cells with varying degrees of atypia, including large cells with increased N/Cratios, coarse chromatin, and prominent nucleoli. All were CD138 positive. Of these, Cytology confirmed malignancy in 19/21(90%) cases. Five cases were positive for kappa-light chain and eight cases for lambda-light chain. Cytogenetics of 3/7 cases showed normal karyotype and 4/7 cases showed complex-karyotype. The patients with kappa light-chain had better survival compared to lambda light-chain (p = 0.051, log rank test). CONCLUSION: ME in PCM can present early in the natural history of the disease or very late. The preponderance of IgA-myeloma and complex-cytogenetics abnormalities is a noteworthy finding. Although there are different hypotheses regarding how ME develops in PCM, our finding supports the hypothesis that direct spread of PCM into serous cavities is a likely mechanism. Diagn. Cytopathol. 2016;44:742-747. © 2016 Wiley Periodicals, Inc.

Vaginal fine-needle aspiration: A useful alternative to biopsy.

BACKGROUND: Vaginal fine-needle aspiration (FNA) is infrequently performed to assess palpable lesions. We perform the first multi-institutional study to evaluate this procedure. METHODS: We retrospectively reviewed vaginal FNAs performed at two institutions for the past 27 years. Clinical, cytological and histological data were reviewed and tabulated. RESULTS: We identified 43 specimens from 39 patients (mean age 56 years, range 18-86 years). Twenty four patients (62%) had prior malignancies from the following sites: gynecologic tract (22), bladder (1), and breast (1). Twenty four specimens were malignant, 18 were benign (including eight cases from patients with prior malignancy) and one was unsatisfactory. Of 28 FNA specimens from patients with a malignant history, 18 (64%) were positive for malignancy. The most common malignancies were metastatic ovarian carcinoma (50%), squamous cell carcinoma (25%), and uterine cancer (17%). Mean time to metastasis/recurrence was 16 months and was longest in patients with ovarian metastasis (26 months) compared to other malignancies (P = 0.002). The most common benign diagnoses were cysts (33%) and inflammation (22%). In 27 cases with histological correlation, there were 20 true positives, six true negatives and one false negative (sensitivity =95%, specificity =100%). Seven patients had a recent Pap test with two true positives, two true negatives, and three false negatives (sensitivity = 40%, specificity = 100%). CONCLUSION: Vaginal FNA is usually performed to rule out a secondary malignancy, often of ovarian origin. Vaginal metastases from extra-gynecologic sites are rare. FNA is both highly sensitive and specific and may be a safe and effective alternative to biopsy. Diagn. Cytopathol. 2016;44:665-669. © 2016 Wiley Periodicals, Inc.

Fine-needle aspiration of metastatic radiation-induced cutaneous epithelioid angiosarcoma of the breast to the liver: A diagnostic dilemma.

Radiation therapy is a significant risk factor for the development of angiosarcoma. With the increase in breast conservation treatment, the incidence of cutaneous radiation-induced angiosarcoma of the breast is rising. If the angiosarcoma demonstrates epithelioid features, the tumor cells may present a diagnostic dilemma on fine-needle aspiration cytology. We present a case of metastatic radiation-induced cutaneous epithelioid angiosarcoma of the breast to the liver and a review of the literature.