Reduced renal function strongly affects survival and thrombosis in patients with myelofibrosis.

We retrospectively investigated a cohort of 176 myelofibrosis patients (128 primary-PMF; 48 secondary-SMF) from five hematology centers. The presence of chronic kidney disease (CKD) was determined in addition to other clinical characteristics. CKD was present in 26.1% of MF patients and was significantly associated with older age (P < 0.001), higher WBC (P = 0.015), and its subsets (neutrophil, monocyte, and basophil counts), higher platelets (P = 0.001), lower albumin (P = 0.018), higher serum uric acid (P = 0.001), higher LDH (P = 0.022), and the presence of CV risk factors (P = 0.011). There was no significant association with driver mutations, degree of bone marrow fibrosis, PMF/SMF, or DIPSS risk categories (P > 0.05 for all analyses). The presence of CKD was significantly associated with shorter time to arterial (HR = 3.49; P = 0.041) and venous thrombosis (HR = 7.08; P = 0.030) as well as with shorter overall survival (HR 2.08; P = 0.009). In multivariate analyses, CKD (HR = 1.8; P = 0.014) was associated with shorter survival independently of the DIPSS (HR = 2.7; P < 0.001); its effect being more pronounced in lower (HR = 3.56; P = 0.036) than higher DIPSS categories (HR = 2.07; P = 0.023). MF patients with CKD should be candidates for active management aimed at the improvement of renal function. Prospective studies defining the optimal therapeutic approach are highly needed.

Liver elastography malignancy prediction score for noninvasive characterization of focal liver lesions.

BACKGROUND & AIMS: To analyse elastographic characteristics of focal liver lesions (FLL)s and diagnostic performance of real-time two-dimensional shear-wave elastography (RT-2D-SWE) in order to differentiate benign and malignant FLLs. METHODS: Consecutive patients diagnosed with FLL by abdominal ultrasound (US) underwent RT-2D-SWE of FLL and non-infiltrated liver by intercostal approach over the right liver lobe. The nature of FLL was determined by diagnostic work-up, including at least one contrast-enhanced imaging modality (MDCT/MRI), check-up of target organs when metastatic disease was suspected and FLL biopsy in inconclusive cases. RESULTS: We analysed 196 patients (median age 60 [range 50-68], 50.5% males) with 259 FLLs (57 hepatocellular carcinomas, 17 cholangiocarcinomas, 94 metastases, 71 haemangiomas, 20 focal nodular hyperplasia) of which 70 (27%) were in cirrhotic liver. Malignant lesions were stiffer (P < .001) with higher variability in intralesional stiffness (P = .001). The best performing cut-off of lesion stiffness was 22.3 kPa (sensitivity 83%; specificity 86%; positive predictive value [PPV] 91.5%; negative predictive value [NPV] 73%) for malignancy. Lesion stiffness <14 kPa had NPV of 96%, while values >32.5 kPa had PPV of 96% for malignancy. Lesion stiffness, lesion/liver stiffness ratio and lesion stiffness variability significantly predicted malignancy in stepwise logistic regression (P < .05), and were used to construct a new Liver Elastography Malignancy Prediction (LEMP) score with accuracy of 96.1% in validation cohort (online calculator available at http://bit.do/lemps). CONCLUSION: The comprehensive approach demonstrated in this study enables correct differentiation of benign and malignant FLL in 96% of patients by using RT-2D-SWE.

[From unexplained fever to visceral leishmaniasis--a case report]. / Od nejasne vrucice do visceralne lismenijaze--prikaz bolesnika.

Visceral leishmaniasis or kala-azar is a systemic infectious vector-borne disease caused by protozoa Leishmania donovani and Leishmania infantum that are transmitted to mammalian hosts by sand flies. It occurrs sporadically in endemic areas, including Mediterranean basin. Southern coastal territories of Croatia have been recognized as the foci of the disease. Dogs are the main reservoir of human infection. Clinical features include prolonged fever, malaise, hepatosplenomegaly, pancytopenia and inversion of albumin-globulin ratio. If left untreated, the disease causes death in majority of cases. We report a 47-year-old Croatian patient who was admitted to hospital with 2-month history of fever of unknown origin. Based on bone marrow aspirate findings and positive serological tests, the diagnosis of visceral leishmaniasis was established. We also considered secondary hemophagocytic lymphohystiocytosis in the differential diagnosis. After a 4-week treatment with sodium-stibogluconate clinical remission was achieved as well as complete recovery of hematopoesis. The aim of our case-report is to stress the importance of considering visceral leishmaniasis in patients with longstanding fever in endemic areas.

Higher serum uric acid is associated with higher risks of thrombosis and death in patients with primary myelofibrosis.

BACKGROUND: Serum uric acid (SUA) can promote inflammation and is associated with increased cardiovascular morbidity. Primary (PMF) and secondary myelofibrosis (SMF) are myeloproliferative neoplasms characterized by high cellular turnover and substantial risk of thrombosis and death. METHODS: We have retrospectively investigated SUA in 173 patients with myelofibrosis (125 PMF; 48 SMF) and 30 controls. RESULTS: The PMF patients had significantly higher SUA in comparison to SMF and controls. In both PMF and SMF higher SUA was significantly associated with arterial hypertension and decreased renal function. Among PMF patients, higher SUA was significantly associated with older age, larger spleen, higher white blood cell counts, higher lactate dehydrogenase, lower immunoglobulin G levels, allopurinol use and non-smoking. Among SMF patients, higher SUA was associated with male sex (P < 0.05 for all analyses). In PMF higher SUA was univariately associated with inferior survival (> 427 µmol/L hazard ratio (HR) = 2.22; P = 0.006) and shorter time to thrombosis (> 444 µmol/L HR = 5.05; P = 0.006), which could be shown separately for arterial (> 380 µmol/L; HR = 4.9; P = 0.013) and venous thromboses (> 530 µmol/L; HR = 17.9; P < 0.001). In multivariate analyses, SUA remained significantly associated with inferior survival independent of the Dynamic International Prognostic Staging System and with shorter time to thrombosis independent of age in PMF patients; however, the prognostic significance of SUA was diminished after including serum creatinine in the models. SUA was not prognostic in SMF patients. CONCLUSION: The PMF patients present with higher SUA levels, which are associated with features of more advanced disease and higher risks of arterial and venous thrombosis and death.

Two Needle Passes Achieve Similar Diagnostic Yield Compared to Three Passes Regarding Diagnosis of Solid Pancreatic Lesions in Endoscopic Ultrasound-Guided Fine Needle Aspiration.

Current guidelines advocate 3-4 passes with a fine-needle aspiration (FNA) to achieve high rates of diagnostic samples for malignancy when performing endoscopic ultrasound (EUS)-guided sampling of solid pancreatic lesions, in the absence of on-site cytologic evaluation. The aim of this study is to compare 2 vs. 3 needle passes in EUS-FNA for solid pancreatic lesions in terms of incremental diagnostic yield and to identify factors associated with the procedure's outcome. In this retrospective study, 2 passes of EUS-FNA were found to have similar diagnostic yield compared to 3 passes for the diagnosis of solid pancreatic masses, suggesting that there might be no significant incremental tissue yield when 3 passes are performed.

Detection of t(14;18) by PCR of IgH/BCL2 fusion gene in follicular lymphoma from archived cytological smears.

According to WHO classification follicular lymphoma (FL) is a neoplasm composed of follicle centre (germinal centre) B-cells, which usually has at least a partially follicular pattern. Bone marrow (BM) infiltration by lymphoma occurs in 40-70% of cases at the time of diagnosis. The characteristic chromosomal translocation of follicular lymphoma is t(14;18)(q32;q21) with transposition of BCL2 oncogene to the regulatory region of immunoglobulin heavy chain gene IgH. Aim of this study was to determine the frequency of PCR detection of IgH/BCL2 in DNA samples isolated from archival cytological slides of lymph node aspirates, bone marrow and/or peripheral blood (PB) obtained from patients with histologically confirmed follicular lymphoma using primers and protocol proposed by BIOMED-2 consortium. We also compared molecular with cytomorphological findings in bone marrow/peripheral blood and tested this method of detection of IgH/BCL2 molecular marker in monitoring minimal residual disease (MRD) in routine clinical setting. DNA was successfully isolated from all archival cytological slides obtained by fine needle aspiration of lymph nodes as well as from 75% of smears of bone marrow aspirates from 19 patients. Fusion oncogene was detected in 10 of 19 patients (52%). For patients with PCR IgH/BCL2 positive lymph nodes, molecular test found BM infiltration in 5 cases (83%), while cytomorphology detected infiltration in three of eight cases (37%) available for comparison. May-Grünwald-Giemsa stained cytological smears can be used for PCR-based ancillary methods and the rate of detection of IgH/BCL2 rearrangement is similar to results reported for paraffin-embedded tissues. For patients with detectable baseline molecular marker, PCR is a highly suitable method for detection of bone marrow involvement and monitoring MRD.

Fine needle aspiration cytology of metastatic Merkel cell carcinoma.

Merkel cell carcinoma (MCC) is uncommon cutaneous malignant neuroendocrine tumour of the elderly people with rapidly growing skin nodules found frequently on sun-exposed areas of the body. MCC is often an aggressive tumour with high tendency for local recurrence, lymph node involvement and distant metastases. This paper reports a case of metastatic MCC diagnosed by fine needle aspiration cytology (FNAC), flow cytometric deoxiribonucleated acid (DNA) analysis, pathohistology and electron microscopy. The cytological features in aspirate (stained with Papenheim and Papanicolaou staining) included increased cellularity, discohesive groups of small-to-medium size malignant cells with uniform, round-to-oval nuclei with moulding effect, fine chromatin, multiple micronucleoli and scanty cytoplasm. DNA flow cytometric analysis of the aspirate showed unexpected results for clinically aggressive behaviour of this tumour (the patient died after 21 months), and revealed that tumour contained diploid peak with DNA index of 1.1. The proliferation was high with elevated S-phase fraction (21%). The cytological diagnosis of possible metastatic MCC was confirmed by histological one as well as by electron microscopy presented the pathognomonic features for this tumour: dense-core neurosecretory granules with diameter of 100-250 nm surrounded by whorls of intermediate filaments. MCC provides an enormous challenge for the morphologist because of a wide range of differential diagnosis and for the clinician because this tumour has a highly malignant potential for local recurrence, nodal and distant spread and very often is combined with other tumours. Therefore it is important to perform FNAC of different lesions in the same patient because it can distinguish MCC from the other tumours.

Biliary brush cytology for the diagnosis of malignancy: a single center experience.

Differentiation between benign and malignant biliary strictures is critical to the provision of adequate treatment. Brush cytology during the endoscopic retrograde cholangiopancreatography (ERCP) is the most commonly used method for obtaining tissue confirmation of the nature of biliary strictures. It's specificity is remarkably high but reported sensitivities for the diagnosis of malignancy are low. Aim of our study was to assess sensitivity and specificity of biliary brush cytology in our institution, to find out main causes of false negative diagnoses and to confirm impression that the team approach has impact on sensitivity. Gold standard for diagnosis was definitive surgical histology or adequate clinical follow up for minimum of six month. Direct smears made by cytotechnician at the endoscopy room, and stained according to Papanicolaou and May-Grünwald Giemsa (MGG) were examined for well-recognized features of malignancy on conventional smears as a part of diagnostic routine. Cytologic diagnoses were benign, atypical/reactive, suspicious for malignancy and malignant. Of 143 brushings with available definitive diagnosis 36 (25%) had malignant cytologic diagnosis and 91(63.6%) were classified as benign, 3 were atypical/reactive and 13 suspicious for malignancy with 20 "false-negative" cases. When specimens with atypical and suspicious cytology were excluded from data analysis sensitivity was 64% and specificity was 100% and when suspicious findings were taken into account as true positives sensitivity rose to 71%. We find that biliary brush cytology, although mainly depending on the skill of endoscopist, as well as the experience of the cytologist, is a valuable method for obtaining accurate tissue diagnosis of biliary strictures, thus solving eternal diagnostic dilemma: benign or malignant.

Flow cytometric analysis of deep-seated lymph nodes.

Flow cytometry (FC) immunophenotyping is an important tool in the evaluation of lymphadenopathy and is widely used in the diagnosis of non-Hodgkin's lymphomas (NHLs) on fine-needle aspirates of lymph nodes and extranodal sites. Because at least 80% of NHLs are of B-cell type, detection of immunoglobulin (Ig) light-chain-restriction is the most commonly used method for confirmation of monoclonality. The aim of our study was to evaluate usefulness of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for FC analysis from deep-seated lymph nodes and to compare results of FC clonality analysis to cytomorphologic diagnosis of sampled lymph nodes. For cytological diagnosis direct smears were made, selected slide was stained for rapid-on site evaluation procedure. Sixteen patients with suspected NHL of deep-seated lymph nodes obtained by EUS-FNA were submitted for FC clonality analysis using four-color multiparameter flow cytometry stained with kappa/lambda/CD19/CD45. Clonality analysis was performed on 11 samples. Monoclonality was demonstrated in seven of 11 cases cytologically diagnosed as NHL and four of 11 cases cytologically diagnosed as benign were polyclonal. Our results show that EUS-FNAC with FC is a sensitive and specific tool in the diagnosis of deep-seated B-NHL. Cytologic diagnosis combined with FC clonality analysis can be performed in majority of cases and may eliminate need for open biopsy in some cases.

Intraoperative imprint cytological assessment of the subareolar tissue of the nipple areola complex (NAC).

One of the criteria of selection for skin sparing mastectomy (SSM) with nipple areola complex (NAC) preservation is to exclude the neoplastic involvement of subareolar tissue (NAC base) in order to minimize the possibility of local recurrence. The most common way to assess the possible neoplastic involvement is intraoperative frozen section of the NAC base tissue. Because of its limitations, particularly the false negative results due to unsampling, we tried to use intraoperative imprint cytology for more thorough intraoperative assessment. The aim was to compare intraoperative imprint findings with the definitive histology of the NAC base, to evaluate diagnostic accuracy of this method and possibility to substitute frozen section for intraoperative assessment of NAC base. A prospective clinical study was conducted of 208 consecutive female patients who underwent open biopsy because of carcinoma. Intraoperative imprints were taken from the excised subareolar tissue which was then routinely processed for definitive histology. Imprint findings designated positive, negative, suspicious or atypia, were compared with definitive histological findings. Our results with 7.5% false negative rate, 9.8% false positive rate, sensitivity of 50% and specificity of 87.58% argue that imprint cytology might not be sufficient as an exclusive method for the intraoperative assessment of the NAC base though it should be used routinely in conjunction with frozen section examination.

Endoscopic ultrasound in solid pancreatic masses--current state and review of the literature.

Some 25 years ago endoscopic ultrasound (EUS) was introduced in clinical practice for better visualization of pancreas. At the time of introduction EUS was superior to other methods in detection of pancreatic masses allowing tissue diagnosis by later introduced EUS-guided fine needle aspiration (FNA). During the time EUS was improved, electronic probes replaced mechanical probes adding ability of color Doppler, power Doppler, contrast enhanced endosonography as well as EUS elastography analysis. Meanwhile, CT technology has also experienced significant improvements raising the question whether EUS has lost ground in diagnostics of solid pancreatic masses. The aim of this review was to discuss the current evidence of clinical impact of EUS and EUS-FNA in evaluation of solid pancreatic masses with special emphasis on differentiation between benign and malignant pancreatic lesions. According to the literature, the detection of small pancreatic tumors, preoperative localization of pancreatic endocrine tumors and tissue sampling by fine-needle aspiration of pancreatic masses in cases with therapeutic consequences are considered firm indications for EUS. Cytological tissue analysis remains undisputed in differentiation benign from malignant lesions, but the question when FNA is needed is discussed. Color Doppler, power Doppler, contrast enhanced endosonography and especially elastography are also discussed as tools that are bringing additional information in evaluation of pancreatic masses, however insufficient for definitive judgment of the lesion's nature. Pancreatic cancer staging as indication for EUS is discussed controversially, inconsistent results and conflicting evidence in literature making adequate conclusion impossible. However, this indicates that at least the role of EUS is no longer undisputed in this matter. Resuming the role of EUS we can state that despite some controversies EUS is very valuable method in evaluation of solid pancreatic masses and with EUS guided FNA is nowadays by far the best method for obtaining tissue diagnosis.

The accuracy of fine needle aspiration cytology and flow cytometry in evaluation of nodal and extranodal sites in patients with suspicion of lymphoma.

Today lymphomas are defined according to a combination of morphology, immunophenotype, genetic features and clinical presentation, so beside the pure cytomorphologic analysis in diagnosis of lymphoma ancillary techniques such as cytochemistry, immunocytochemistry, molecular diagnosis and flow cytometry (FC) are often used. Our goal was to determinate how is information given by fine-needle aspiration cytology (FNAC) and FC correlated with pathohistologic diagnosis and to evaluate ability to diagnose and subclassify malignant lymphomas by FNAC and FC. This study is a retrospective chart review of patients with suspicion of lymphoma processed at University Hospital Dubrava in Zagreb. After analysis 50 patients fulfilled inclusion criteria for this study (FNAC diagnosis with or without FC and consecutive confirmatory pathohistological diagnosis). When analyzing accuracy of FNAC according to suspicion of lymphoma or NHL and differential diagnosis lymphoma sensitivity was 97.7%, specificity 85.7% and the diagnostic accuracy was 96%. When analyzing accuracy of FNAC according to the subclassification of lymphoma, sensitivity was 74.4%, specificity 85.7% and the diagnostic accuracy 76%. Combined FNAC and FC improved sensitivity, positive predictive value, negative predictive value and diagnostic accuracy. Sensitivity was 79.1% and the diagnostic accuracy 80%. We have shown that these methods can distinguish benign lymphadenopaties from lymphomas and also subclassify lymphomas and quickly provide clinicians with that information.

Misleading presentations of malignant breast diseases--role of clinical cytology.

We described two examples with misleading presentations to draw attention to the role of clinical cytology as apart of multidisciplinary approach to breast lesions. In the first case--Paget's disease of the nipple, there was no obvious clinical and radiological evidence of breast cancer, while the second case--primary non-Hodgkin lymphoma of the breast imitated advanced breast carcinoma. The question is whether accurate and fast diagnoses can be made without cytological examinations. It must be kept in mind that first-hand clinical information and contact with the patient is necessary in rendering accurate cytological diagnoses.

Insulin-like growth factor 2 binding protein 3 expression on endoscopic ultrasound guided fine needle aspiration specimens in pancreatic ductal adenocarcinoma.

BACKGROUND: Despite numerous investigations, we still do not have a specific marker for pancreatic ductal adenocarcinoma. Only guideline-recommended biomarker for pancreatic ductal adenocarcinoma is the CA19-9, but it is also present in other gastrointestinal diseases. IMP3 is a new potential biomarker that is over-expressed in some cancers. The aims of our study were (1) to assess IMP3 in benign pancreatic lesions and pancreatic cancer, and (2) to estimate its concentrations in localized and advanced pancreatic cancer. PATIENTS AND METHODS: Seventy-five patients with solid pancreatic lesions who underwent EUS-FNA were included. Patients were divided into three groups: benign lesions, cancer localized only on the pancreas, and patients with advanced pancreatic cancer (locally advanced or with distal metastases). Immunoreactivity of IMP3 was assessed on cytological smears sampled by endoscopic ultrasound. RESULTS: IMP3 was expressed in 89% of the patients with pancreatic cancer and not in benign lesions. Stronger expression of IMP3 protein and stage of the pancreatic cancer was statistically significant. IMP3 was expressed in all localized cancers and in 85% of patients with advanced pancreatic cancer. In the subgroup with locally advanced cancer, IMP3 was expressed in 88%, and in 83% of patients in the subgroup with distal metastasis (P = 0.007). In the present study, sensitivity was 89%, specificity 100%, with positive predictive value of 100% and negative predictive value of 63%. CONCLUSION: There is a positive correlation between IMP3 expression and TNM stages of the pancreatic cancer. Higher expression of IMP3 on EUS-FNA specimens can suggest poorer prognosis.