Vaping-Associated Acute Respiratory Failure Due to Acute Lipoid Pneumonia.

Electronic cigarettes, pens, cartridges and other devices were developed as nicotine delivery systems not requiring combustion of tobacco leaves. This technology was subsequently employed to deliver the cannabis component tetrahydrocannabinol (THC) via products often manufactured without adequate quality oversight and sold illegally. Recently, five patients presenting within a 2-month period with acute respiratory failure due to acute lipoid pneumonia after inhaling THC-containing concentrates or oils have been described. We report a 28-year-old previously healthy man who presented in acute respiratory failure 2 weeks after initiating use of a street-purchased THC-containing vape cartridge. Bronchoalveolar lavage cytology with oil red O staining confirmed the diagnosis of acute lipoid pneumonia. Diffuse alveolar hemorrhage and eosinophilic pneumonia were excluded. Evolving evidence supports a clinical entity of acute respiratory failure due to acute, exogenous lipoid pneumonia induced by THC-containing concentrates or oils inhaled through a variety of vaping products. All six patients reported to date received intravenous corticosteroids and survived to hospital discharge.

A worm in the cytology laboratory: A root cause analysis case study.

In the spring of 2018, nematode-like organisms were first noted at the time of microscopic diagnosis on gynecologic (GYN) and anal pap specimens in our institution's cytopathology department. Due to their morphology and specimen source, we considered a diagnosis of pinworm. However, after identifying at least 30 more cases over 3 months from patients living in variable locations, we started favoring a contaminant. This report studies the steps that were initiated to figure the source of pap smear-preparation contamination and the molecular investigation to identify the nature of the contaminant.

Low-grade squamous intraepithelial lesion, cannot rule out high-grade lesion: Diagnosis, histological outcomes and human papillomavirus results.

BACKGROUND: The 2014 Bethesda System for Reporting Cervical Cytology classifies squamous intraepithelial lesions (SILs) of cervix into two main categories: low-grade SIL (LSIL) and high-grade SIL (HSIL). In some clinical practices, the LSIL cannot rule out high-grade lesion (LROH) interpretive category is used in cases with LSIL and findings that may raise the possibility of HSIL. Our purpose is to assess follow-up histopathology and high-risk human papillomavirus (hrHPV) results in patients with LROH, in comparison with LSIL, atypical squamous cells, cannot rule out HSIL (ASC-H), and HSIL in our institution. DESIGN: Cervical Papanicolaou tests with LROH, LSIL, ASC-H and HSIL interpretation, surgical follow-up, and hrHPV status were retrieved from the computer database from May 2014 to December 2016. RESULTS: Of 109 963 total Papanicolaou tests, LROH comprised 0.3%, LSIL 3.1%, ASC-H 0.2% and HSIL 0.4%. Only 3272 cases with surgical diagnoses were included in the study. The most common histological outcome for ASC-H was cervical intraepithelial neoplasia (CIN)2/3 (32.6%); LSIL was CIN 1 (45.7%); LROH was CIN 1 (46.7%) and HSIL was CIN 2/3 (64.4%). For LROH and LSIL, 31.1% and 7.5% respectively, had CIN 2/3. Approximately 79% of cases were hrHPV positive. Of LROH cases with surgical follow-up, 86.9% tested hrHPV positive, accounting for the second most common positive group after HSIL (92.6%). CONCLUSION: In our study cohort, LROH interpretation is associated with a higher number of CIN 2 or higher lesions on follow-up compared to patients with LSIL (P < 0.0001), and is associated with a significant percentage of positive other hrHPV, supporting LROH as a useful diagnostic category that triggers appropriate follow-up in affected women.

Educational Case: Thyroid Neoplasms: Pathogenesis, Diagnosis, and Treatment.

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.

Educational Case: Endocrine Neoplasm: Medullary Thyroid Carcinoma.

Medullary thyroid cancer is a rare neuroendocrine tumor that arises the neural crest-derived parafollicular C cells and accounts for approximately 5% to 10% of thyroid cancers worldwide. These tumor can occur sporadically or as part of hereditary tumor syndromes, such as multiple endocrine neoplasia 2 and familial medullary thyroid cancer. The most common clinical presentation is a solitary thyroid nodule. The genetic defect in these disorders involves the RET proto-oncogene which is important for diagnosis of medullary thyroid cancer (including screening for hereditary medullary thyroid cancer) and for treatment guidance. This review summarizes the molecular basis and clinicopathologic features of medullary thyroid carcinoma.

Incidental primary mediastinal choriocarcinoma diagnosed by endobronchial ultrasound-guided fine needle aspiration in a patient presenting with transient ischemic attack and stroke.

We describe a case of a 41-year old male patient with no significant prior medical history who presents with symptoms of Transient Ischemic Attack and stroke. Magnetic Resonance Imaging (MRI) of the brain identified areas of ischemia in the left side, and angiography showed occlusion of the left Medial Cerebral Artery (MCA). Cardiac Transthoracic Echocardiogram (TTE) for stroke evaluation incidentally noted a mediastinal abnormality leading to cancer work-up. Computer Tomography (CT) and 18 F-fluorodeoxyglucose (FDG) PET-CT scan of the chest incidentally revealed an avid 6 cm paraesophagial/subcarinal mass. Further diagnostic work-up with endoscopic and endobronchial ultra sound (EBUS)-guided fine needle aspiration (FNA) of the mass yielded a cytology diagnosis of Germ Cell Tumor (GCT), with choriocarcinoma component. Additionally, high plasma levels of ß-human chorionic gonadotrophin (ß-HCG) were detected with no evidence of testicular tumor. This exceedingly rare presentation for a primary mediastinal choriocarcinoma underscores the importance of complete investigation of young patients presenting with neurological symptoms compatible with ischemic events. Diagn. Cytopathol. 2017;45:738-743. © 2017 Wiley Periodicals, Inc.

The Application of Molecular Diagnostics to Stained Cytology Smears.

Detection of mutational alterations is important for guiding treatment decisions of lung non-small-cell carcinomas and thyroid nodules with atypical cytologic findings. Inoperable lung tumors requiring further testing for staging and thyroid lesions often are diagnosed using only cytology material. Molecular diagnostic tests of these samples typically are performed on cell blocks; however, insufficient cellularity of cell blocks is a limitation for test performance. In addition, some of the fixatives used while preparing cell blocks often introduces artifacts for mutation detection. Here, we applied qClamp xenonucleic technology and quantitative RT-PCR to cells microdissected directly from stained cytology smears to detect common alterations including mutations and translocations in non-small-cell carcinomas and thyroid lesions. By using this approach, we achieved a 1% molecular alteration detection rate from as few as 50 cells. Ultrasensitive methods of molecular alteration detection similar to the one described here will be increasingly important for the evaluation of molecular alterations in clinical scenarios when only tissue samples that are small are available.

Hybrid Capture 2 human papillomavirus testing of fine needle aspiration cytology of head and neck squamous cell carcinomas.

BACKGROUND: Human papillomavirus (HPV) positive head and neck squamous cell carcinoma (HNSCC) accounts for 25% of HNSCCs and frequently presents with neck lymph node metastases. We investigated utilizing cytology needle rinse material for HPV DNA testing by Hybrid Capture 2 molecular testing (HC2) as an alternative to p16 immunohistochemistry. METHODS: Twenty-two cases of HNSCC presenting with neck lymph node metastasis were prospectively identified by assessment of Diff Quik stained cytology smears. An aliquot of the needle rinse material from the lymph node was analyzed for HPV status using standard HC2 protocol. P16 status was determined with immunohistochemistry on the cell block and/or surgically obtained tumor. RESULTS: The mean age of patients with p16 negative HNSCC was 7 years older than p16 positive disease (Table ). Primary tumor subsites were as follows: 17 oropharynx, 1 hypophayrnx, 3 larynx, and 1 oral cavity (Table ). All ten p16 negative patients had a history of smoking compared with 33% of p16 positive. Only 3 (25%) of p16 positive tumors demonstrated keratinization, whereas 90% of the p16 negative tumors keratinized (Fig. 1). Twelve of 22 HNSCC cases (55%) were p16 positive, of which 7 (58%) tested positive for HPV by HC2. Ten cases (45%) were negative for p16, all of which were negative for HPV by HC2 (Table ). CONCLUSION: Molecular testing for HPV using HC2 on needle rinse material of FNA of HNSCC is a useful method of determining HPV status in HNSCC.

Recurrent Immunodeficiency-Associated Burkitt Lymphoma Presenting as Severe Anterior Uveitis.

PURPOSE: To report a case of recurrent immunodeficiency-associated Burkitt lymphoma (BL) that initially presented as severe anterior uveitis. METHODS: Case report. RESULTS: To our knowledge, this is the first reported case of isolated anterior uveitis related to immunodeficiency-associated BL. A 34-year-old African American woman with a history of HIV and BL in remission presented with unilateral anterior uveitis. Histopathologic study of an aqueous humor specimen was consistent for BL. CONCLUSION: The patient's initial presentation masqueraded as anterior uveitis, but her condition rapidly progressed with significant central nervous system involvement. Ocular involvement of immunodeficiency-associated BL is rare, with isolated anterior uveitis being even rarer. This must be kept in mind in the differential diagnosis for any patient with immunodeficiency, especially with a history of previous BL.

Estrogen, progesterone, and HER-2 receptor immunostaining in cytology: the effect of varied fixation on human breast cancer cells.

The ASCO/CAP Expert Panel recommends that all invasive breast carcinomas and breast cancer recurrences be tested for ER, PR and HER-2 expression. The guidelines for testing of surgical specimens by immunohistochemistry (IHC) are well defined, whereas they are lacking for cytological samples. We evaluated various fixation protocols for optimal receptor testing by immunohistochemistry and immunocytochemistry (ICC) of human breast cancer cell lines MCF-7 (ER/PR positive) and SKBR-3 (overexpressing HER-2). The cells were fixed in 10% neutral buffered formalin or Saccomanno Fixative (SF) for various time points, and either embedded in paraffin as cell blocks or prepared as cytospins. ER and PR slides were assigned a proportion score (PS; 0-5), an intensity score (IS; 0-3) and a total score (TS = PS + IS). Standard DAKO scoring system ranging from 0 to 3+ was used for the evaluation of HER-2 staining. Human breast cancer cells stained successfully for ER, PR and HER-2 when fixed in formalin and prepared as cell blocks. The optimal fixation time for formalin-fixed cells ranged from 2 to 96 hours. Cells fixed in SF from 2 to 96 hours also stained well for ER and PR. However, SF produced variable results for HER-2 staining; particularly, SF fixation beyond 24 hours caused false negative results. The interpretation of HER-2 staining on cytospins was not feasible irrespective of the fixative and fixation time. In summary, formalin fixation from 2 to 96 hours and preparation of cells as cell blocks produces optimal results for ER, PR, and HER-2 testing in human breast cancer cells.

High prevalence of high grade anal intraepithelial neoplasia in HIV-infected women screened for anal cancer.

There is no consensus on optimal screening for anal cancer (AC) in HIV+ women. Seven hundred fifteen unique asymptomatic women in a high-prevalence HIV+ community were screened for AC with anal cytology and triage to high-resolution anoscopy after routine screening was implemented in a large urban hospital system. Of these, 75 (10.5%) had an abnormal anal cytology and 29 (38.7%) of those with an abnormality had high-grade anal intraepithelial neoplasia (AIN). Women with poorly controlled HIV were significantly more likely to have high-grade AIN (P = 0.03). Given the high rate of AIN in screened HIV-infected women, routine AC screening in all HIV-infected women should be strongly considered.

Fine needle aspiration of follicular dendritic cell sarcoma in an HIV-positive man: a case report.

BACKGROUND: Follicular dendritic cell (FDC) sarcoma is an uncommon neoplasm occurring not only in lymph nodes but also in extranodal sites. Because of an increasing number of case reports, awareness of this tumor has grown. The nature of the disease and its relation to other diseases, treatment, prognosis and immunochemistry findings are being actively studied. So far, only a limited number of cytology cases describing the fine needle aspiration (FNA) biopsy findings of FDC sarcoma have been reported. CASE: A 47-year-old man had a history of hypertension and human immunodeficiency virus (HIV) infection treated with antiretroviral therapy. He developed a slowly growing, nontender right neck mass over the course of 3 years. FNA revealed sheets and thick syncytial clusters of bland cells with pale cytoplasm and indistinct cell borders, round to oval nuclei with fine or vesicular chromatin, and small nucleoli. The mass was subsequently excised. A diagnosis of FDC sarcoma was made based on the histologic appearance and the marker studies. Conclusion The diagnosis ofFDC sarcoma in FNA can be suspected if a pathologist is aware of its characteristic features. Research studies have demonstrated the presence of HIV-related FDC hyperplasia. It is likely that HIV infection may have played a role in tumor formation in this patient. (Acta

APTIMA assay on SurePath liquid-based cervical samples compared to endocervical swab samples facilitated by a real time database.

BACKGROUND: Liquid-based cytology (LBC) cervical samples are increasingly being used to test for pathogens, including: HPV, Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) using nucleic acid amplification tests. Several reports have shown the accuracy of such testing on ThinPrep (TP) LBC samples. Fewer studies have evaluated SurePath (SP) LBC samples, which utilize a different specimen preservative. This study was undertaken to assess the performance of the Aptima Combo 2 Assay (AC2) for CT and GC on SP versus endocervical swab samples in our laboratory. MATERIALS AND METHODS: The live pathology database of Montefiore Medical Center was searched for patients with AC2 endocervical swab specimens and SP Paps taken the same day. SP samples from CT-and/or GC-positive endocervical swab patients and randomly selected negative patients were studied. In each case, 1.5 ml of the residual SP vial sample, which was in SP preservative and stored at room temperature, was transferred within seven days of collection to APTIMA specimen transfer tubes without any sample or patient identifiers. Blind testing with the AC2 assay was performed on the Tigris DTS System (Gen-probe, San Diego, CA). Finalized SP results were compared with the previously reported endocervical swab results for the entire group and separately for patients 25 years and younger and patients over 25 years. RESULTS: SP specimens from 300 patients were tested. This included 181 swab CT-positive, 12 swab GC-positive, 7 CT and GC positive and 100 randomly selected swab CT and GC negative patients. Using the endocervical swab results as the patient's infection status, AC2 assay of the SP samples showed: CT sensitivity 89.3%, CT specificity 100.0%; GC sensitivity and specificity 100.0%. CT sensitivity for patients 25 years or younger was 93.1%, versus 80.7% for patients over 25 years, a statistically significant difference (P = 0.02). CONCLUSIONS: Our results show that AC2 assay of 1.5 ml SP samples transferred to APTIMA specimen transfer medium within seven days is sufficiently sensitive and specific to be used to screen for CT and GC. CT sensitivity may be somewhat reduced in samples from patients over 25 years. SP specimens retained in the original SP fixative for longer time intervals also may have decreased sensitivity, due to deterioration of RNA, but this was not assessed in this study. The ability to tap the live pathology database is a valuable tool that can useful to conduct clinical studies without a costly prospective clinical trial.

Discrepant cytologic and radiographic findings in adjacent galactocele and fibroadenoma: a case report.

BACKGROUND: Clinical, radiologic and pathologic evaluation of a breast mass during pregnancy and lactation often presents a challenge. We report a case of a longstanding benign breast mass that was negative on fine needle aspiration biopsy (FNAB) but sonographically appeared suspicious for carcinoma. CASE: A 41-year-old patient presented with a long-standing benign breast nodule that increased in size postpartum and became painful. The patient was breastfeeding when she developed mastitis in the surrounding area and was treated with antibiotics. The inflammation resolved, but the original mass persisted. FNA of the mass yielded thick, whitish material that on microscopic examination showed clusters of ductal cells with striking reactive, reparative and lactation changes admixed with amorphous material and crystals. The smear pattern was interpreted as negative. However, the sonogram revealed a solid lesion with mixed echogenicity suspicious for malignancy. The patient underwent lumpectomy, which showed concomitant fibroadenoma and galactocele. CONCLUSION: We suspect that in lactating patients preexisting breast masses may interfere with the milk flow, thus rendering the breast tissue around the mass prone to galactocele formation. This may result in erroneous clinical and radiologic impression of growth and transformation of a preexisting lesion.

Pilomatrixoma in an infant: diagnostic challenges of fine-needle aspiration.

Fine-needle aspiration biopsy (FNAB) is a well-recognized minimally invasive tool in the diagnosis of neoplasia of various organ systems. Several reports in the literature suggest that FNAB can be an accurate method for the preoperative diagnosis and treatment planning. We describe a case to caution the interpretation from a FNAB that contains suboptimal contents (basaloid cells only) and highlight a clinical-pathologic-based algorithm that can provide the appropriate management for the patient when the cytopathologic diagnosis does not fit the clinical impression.

HepPar1, MOC-31, pCEA, mCEA and CD10 for distinguishing hepatocellular carcinoma vs. metastatic adenocarcinoma in liver fine needle aspirates.

OBJECTIVE: To investigate immunohistochemical staining of hepatocyte paraffin-1 (HepPar1), alpha-fetoprotein (AFP), polyclonal carcinoembryonic antigen (pCEA), monoclonal CEA (mCEA), MOC-31 and CD10 for differential diagnosis of hepatocellular carcinoma (HCC) from metastatic adenocarcinoma (MA) on fine needle aspiration biopsy (FNAB). STUDY DESIGN: Fifty-one archival, paraffin-embedded FNAB cell blocks, representing 18 HCCs and 33 MAs, were immunostained with antibodies for AFP, CD10, pCEA, mCEA, HepPar1 and MOC-31. RESULTS: HepPar1, AFP, canalicular pCEA and CD10 were positive in 78% (14 of 18), 28% (5 of 18), 72% (13 of 18) and 35% (6 of 17) of cases of HCC, respectively. The 33 MAs were negative for immunostaining of the above antibodies except for one AFP-positive MA. Ninety-seven percent (31 of 32) of the MAs and 6% (1 of 17) of the HCCs were positive for MOC-31. Monoclonal CEA was immunoreactive on 82% (27 of 33) of the MAs and negative on all the HCCs. CONCLUSION: HepPar1 was the most sensitive marker for HCC, followed by canalicular staining for pCEA. For MA, MOC-31 was the most sensitive marker; mCEA was slightly less sensitive but more specific. We suggest using HepPar1, pCEA, CD10, MOC-31 and mCEA as a panel for distinguishing HCC from MA in liver FNAB.