Pulmonary metastasis of a postradiation breast epithelioid angiosarcoma mimicking adenocarcinoma. A case report.

BACKGROUND: Epithelioid angiosarcoma (EAS) is a mesenchymal neoplasm that may appear indistinguishable from carcinoma, melanoma and other tumors with epithelioid/epithelial differentiation. We report a case of metastatic postradiation EAS to the lungs that was mistaken for adenocarcinoma. CASE: A 45-year-old woman who received radiotherapy for ductal carcinoma in situ (DCIS) 5 years previously had a local recurrence a year earlier and recent development of bilateral small pulmonary nodules. Fine needle aspiration biopsy of the lung lesions showed round to oval tumor cells with amphophilic cytoplasm. An interpretation of adenocarcinoma was rendered during assessment for specimen adequacy. The original breast tumor was typical of cribriform DCIS. Review of the recurrent breast tumor (initially reported as DCIS) and a prior wedge resection of the lung nodules (reported as EAS) showed an epithelial-appearing tumor exhibiting an endothelial immunophenotype CONCLUSION: The cytologic features of EAS may resemble those of other neoplasms. In evaluating tumors with epithelioid morphology, mesenchymal tumors should also be considered so that appropriate antibodies can be included in the panel for immunohistochemistry. The importance of reviewing the patient's previous biopsy materials cannot be overemphasized.

Synovial sarcoma of the heart: Report of a case with diagnosis by endoscopic ultrasound-guided fine needle aspiration biopsy.

BACKGROUND: Primary synovial sarcomas of the heart are aggressive and extremely rare tumors. At least 17 cases have been reported in the literature. In all the published cases the diagnosis was based on histologic sections. To our knowledge, this is the first case of primary synovial sarcoma of the heart diagnosed by fine needle aspiration (FNA). CASE: A 36-year-old male with an unremarkable past medical history presented with a 4.4-cm mass arising from the left ventricular wall of the heart. Endoscopic ultrasound guided fine needle aspiration biopsy of the mass revealed a high grade tumor showing an intimate admixture of spindle and epithelial cells. A diagnosis of undifferentiated sarcoma, favor synovial sarcoma, was rendered. Reverse transcription-polymerase chain reaction demonstrated the presence of a SYT-SSX fusion transcript. The patient received 6 cycles of chemotherapy followed by resection of the residual tumor. The histology of the viable tumor showed histologic findings typical of biphasic synovial sarcoma. CONCLUSION: Synovial sarcoma rarely presents as a primary tumor of the heart. Sampling by FNA allows demonstration of the cytomorphologic appearance typical of the tumor and other ancillary studies. The specific genetic abnormality of these tumors allows confirmation by cytogenetic and molecular studies.

Reclassification of "atypical" diagnoses in endoscopic retrograde cholangiopancreaticography-guided biliary brushings.

OBJECTIVE: To evaluate the usefulness of reclassifying "atypical" diagnoses in reporting biliary cytology using strict morphologic criteria. STUDY DESIGN: Cytologic specimens from 139 patients (direct, alcohol-fixed smears or cytocentrifuge preparations) were evaluated. Diagnoses were benign (70), atypical (36) and malignant (33). Using strict criteria--major (nuclear contour, chromatin pattern) and minor (polarity, cell types, nuclear size, nuclear grooves, nucleoli, mitosis, nuclear/cytoplasmic [N/C] ratio)--atypical cases were reevaluated and reclassified. Follow-up (F/U) was available on all cases. RESULTS: Atypical cases, (36) were reclassified as malignant (26), atypical favor benign (2)/reactive (3) and atypical, not otherwise specified (NOS) (5). Cases reclassified as malignant showed irregular nuclear contours, chromatin irregularities and rare mitosis. Nuclear enlargement, nucleoli and cellularity varied widely in all groups. N/C ratio was increased in most reclassified malignant cases. All 26 malignant reclassifications correlated with F/U of malignancy. Benign and reactive cases (5) were negative for malignancy on F/U (4), and in 1 case a metastatic carcinoma involving the biliary tree was found. In the 5 atypical (NOS) cases, F/U showed malignancy (3) and pancreatitis (2). Cytocentrifuge preparations made in our laboratory were of superior quality when compared to other methods of cell preparation. CONCLUSION: Irregularities in nuclear membrane and abnormal chromatin pattern were the most consistently useful features correlating with malignancy. The sensitivity and specificity of biliary brush cytology can be enhanced by using strict cytomorphologic criteria and proper collection and fixation, all of which decrease atypical diagnoses.