Rothia dentocariosa endocarditis complicated by brain abscess.

A 27-year-old woman is described with Rothia dentocariosa endocarditis, the fourth such case described in the literature. Her course was complicated by brain abscess, which was treated successfully with antibiotics. It is believed this represents the first case of R. dentocariosa with central nervous system involvement.

Solitary fibrous tumor of the lower urogenital tract: a report of five cases involving the seminal vesicles, urinary bladder, and prostate.

Solitary fibrous tumor (SFT) is not as site-restricted as once believed. Initially described as a tumor of the pleura, SFT is now recognized at various extrathoracic sites. We report 5 cases of extrapleural SFT involving the male lower urogenital tract. The tumors involved the seminal vesicles (2 cases), urinary bladder (2 cases), and the prostate (1 case). The patients with bladder tumors were asymptomatic. The patients with seminal vesicle involvement presented with hematuria or groin pain. The patient with prostate involvement presented with urinary retention. The prostate tumor was large, and it could not be completely excised because of its extensive spread beyond the prostate into the pelvis. The other 4 tumors were completely excised, and none has recurred during limited follow-up. By histological criteria, 4 of the tumors were benign, and 1 was malignant. Even though the classic histological features of SFT were well developed in each case, all 5 tumors were initially misdiagnosed, including 3 benign tumors that were misclassified as sarcomas. These 5 cases confirm the male lower genitourinary tract as yet another site of origin for SFTs, challenge the notion that extrapleural SFTs invariably are benign, and draw attention to the problem of recognizing SFTs when they arise in unexpected sites.

Intrathyroidal water-clear cell parathyroid adenoma: a case report.

Adenomas of the parathyroid gland, the majority of which contain mixed cell populations, are the most frequent cause of primary hyperparathyroidism. Parathyroid adenomas composed exclusively of water-clear cells are exceptionally rare. Until now, only 2 cases have been reported in English literature. We report a water-clear cell adenoma of the parathyroid gland in an intrathyroidal position, which has not been described previously according to our knowledge.

Variance in the interpretation of cervical biopsy specimens obtained for atypical squamous cells of undetermined significance.

We sought to determine whether the variability in dysplasia rates in cases of atypical squamous cells of undetermined significance (ASCUS) reflects variability in interpretation of cervical biopsy specimens. In phase 1, 124 biopsy specimens obtained because of a cytologic diagnosis of ASCUS were reviewed independently by 5 experienced pathologists. Diagnostic choices were normal, squamous metaplasia, reactive, indeterminate, low-grade squamous intraepithelial lesion (LSIL), and high-grade squamous intraepithelial lesion (HSIL). The rate of dysplasia ranged from 23% to 51%. All pathologists agreed in 28% of cases. In 52% of cases, the diagnoses ranged from benign to dysplasia. The overall interobserver agreement was poor. In phase 2, 60 cervical biopsy specimens (21 obtained for ASCUS, 22 for LSIL, and 17 for HSIL) were evaluated using the same diagnostic choices. Agreement was better in biopsies performed for HSIL and LSIL compared to those for ASCUS. Intraobserver reproducibility in the interpretation of biopsies performed for ASCUS ranged from poor to excellent. We conclude that variability in the interpretation of biopsy specimens plays an important role in the differences in rates of dysplasia reported for the follow-up of ASCUS.

Aortic dissection in a weight lifter with nodular fasciitis of the aorta.

We report a case of spontaneous aortic dissection in a young weight lifter without aortic medial disease but with a myofibroblastic proliferation of the aortic adventitia consistent with nodular fasciitis. Successful treatment included ascending aorta replacement with Dacron graft and aortic valve resuspension. We believe that the underlying aortic pathology most likely contributed to the development of the aortic dissection.

Adenoid cystic carcinoma: DNA as a prognostic indicator.

A retrospective study was performed on 20 patients with adenoid cystic carcinomas of major salivary glands to see if DNA patterns correlated with their prognoses. Fourteen tumors were found to be DNA diploid; 6 were DNA aneuploid. Histologically, all DNA-aneuploid tumors had solid components, compared with only 5 of the DNA-diploid tumors. All of the DNA-aneuploid tumors recurred, in contrast to only 2 of the DNA-diploid tumors; the difference was highly significant (P less than 0.001). All of the patients with no recurrences had DNA-diploid tumors. In our study, DNA measurements of adenoid cystic carcinomas gave statistically significant information about prognosis and correlated to histological grading. We propose that evaluation of DNA content may be performed before planning the treatment of adenoid cystic carcinomas.

Water-clear cell adenoma of the parathyroid. A case report with immunohistochemistry and electron microscopy.

We report a water-clear cell adenoma of the parathyroid gland, a lesion which to our knowledge has not been described previously. Like its rare but well-described hyperplastic counterpart, water-clear cell hyperplasia, this adenoma is composed of cells with abundant foamy-to-granular cytoplasm and mild nuclear pleomorphism. The cells form glandular structures and cell nests separated by fine fibrovascular septae. The tumor cells stain positively with anti-parathyroid hormone and show characteristic glassy and flocculate material by electron microscopy. Unlike water-clear cell hyperplasia, water-clear cell adenoma is a solitary lesion that compresses the residual nonneoplastic parathyroid gland.

Type IV Ehlers-Danlos syndrome with aspirin sensitivity. A family study.

The purpose of this study was to investigate a family with type IV Ehlers-Danlos syndrome (EDS-IV) and platelet sensitivity to aspirin, an association that, to our knowledge, has not been reported previously. Type IV Ehlers-Danlos syndrome is a rare disorder of type III collagen metabolism characterized by bruising easily and death at an early age from exsanguination by rupture of a major viscus or artery. Previous studies have suggested an association between various types of Ehlers-Danlos syndrome and abnormal platelet function. In this family, EDS-IV is inherited in an autosomal dominant pattern. The transmission of the platelet functional disorder from the proband to only one of two children affected with EDS-IV in this family suggests that there is a genetic component to this condition that is independent of EDS-IV.

Metastatic nasopharyngeal carcinoma: cytologic features of 18 cases.

The cytologic features of 18 fine-needle aspirates (FNAs) of metastatic nasopharyngeal carcinoma from 17 patients were examined. The 12 males and 5 females had a median age of 45 years (range 17-75 years). Six were white, five Oriental, four Hispanic, and two black. All patients had mid- or upper-cervical lymphadenopathy (14 bilateral, 3 unilateral). Seven developed widespread metastasis (bone, 5; lung, 2; liver 1; adrenal, 1; soft tissue, 1). The FNAs were from cervical lymph nodes (15), liver (1), adrenal (1), and soft tissue (1). Most aspirates showed similar cytologic features. Tumor cells were present singly and in syncytial groups with overlapping moderately pleomorphic oval to spindle-shaped nuclei with thin, slightly irregular nuclear contours, moderately hyperchromatic chromatin, and usually one or two prominent nucleoli. The cytoplasm was scant and pale with ill-defined borders. Mitoses were frequent. Mature lymphocytes were common in the background of lymph node aspirates. Electron microscopy and immunocytochemistry confirmed the epithelial nature of the tumor in four cases. Although the cytologic features of metastatic nasopharyngeal carcinoma (NPC) are characteristic, other poorly differentiated neoplasms need to be considered. Clinical and radiologic data are helpful in supporting the cytologic diagnosis.

Cytologic features of deep juvenile xanthogranuloma.

Juvenile xanthogranuloma (JXG) is a rare lesion of the skin and deep tissues whose cytologic features have not previously been published. We report on 2 cases of JXG in patients aged 5 days and 5 yr who presented with an axillary mass and enlarged supraclavicular lymph node, respectively. Fine-needle aspiration and touch imprints made from the surgical biopsies yielded cellular specimens composed of histiocytes, multinucleated Touton-type giant cells, and variable admixtures of lymphocytes and eosinophils. One lesion was composed primarily of benign-appearing histiocytes with admixed multinucleated giant cells and a few lymphocytes. The second lesion consisted of a few histiocytes, occasional Touton giant cells, many lymphocytes, and scattered fibroblasts. The histiocytes were CD68-positive and S100-negative. Histologic follow-up confirmed the diagnosis of juvenile xanthogranuloma. One patient was lost to follow-up; the other is alive without evidence of recurrence 1 yr after surgery. We conclude that deep JXG has characteristic and diagnostic cytologic features.

Immunocytochemistry on the Thinprep processor.

INTRODUCTION: For cytologic specimens, the vast majority of immunocytochemical studies (ICC) are performed on non-gynecologic specimens for diagnostic purposes, and they can be performed on unstained or previously stained direct smears. Although the ThinPrep processor (TPP) has been approved for the preparation of non-gynecologic specimens, there is scant literature describing the utility of ICC methodology on cytology specimens fixed and processed by this method. MATERIALS AND METHODS: Forty-one fresh specimens were obtained from the surgical gross room and aspirated or scraped to collect cells for thin layer (TL) and direct smears (DS). Specimens included a variety of neoplastic and nonneoplastic samples that were either Papanicolaou (P) stained or unstained (US). One group of US TL slides was subjected to antigen retrieval (AR). Staining was graded semiquantitatively. Each sample acted as its own control. Antibodies (abs) included: CAM5.2, AE1/3, K903, vimentin, MSA, desmin, s-100, HMB45, PSA, PAP, chromogranin, NSE, insulin, synaptophysin, pCEA, mCEA, mCEAD14, LCA, L26, UCHL-1, OPD-4, thyroglobulin, GCDFP, ER/PR, laminin, collagen IV, PLAP, HCG, CD68, HAM56, and MAC387. RESULTS: Semiquantitative staining overall results comparisons: TLP > DSP TLP < DSP TLP = DSP TLUS > DSUS 11/25 (44%) 6/25 (24%) 8/25 (32%) 9/24 (38%) TLUS < DSUS TLUS = DSUS 3/24 (12%) 12/24 (50%) TLP Vs. TLUS TLP > TLUS TLP < TLUS TLP = TLUS 8/41 (20%) 9/41 (22%) 24/41 (58%) There were five false-negative results, 2 with TL and 3 with DS, and 1 false-positive TL. DISCUSSION: Immunocytochemistry performed on the ThinPrep Processor showed equal or greater intensity and distribution of proper staining when compared to direct smears with the following advantages: (1) cleaner background, easier to interpret; (2) less abs required in a smaller area; (3) IPX can be done on Papanicolaou-stained thin layer slides; (4) thin layer slides can be modified for multiple abs tests; (5) additional thin layer slides can be prepared for ICC bases on needs. No significant differences of immunostaining were seen when comparing thin layer Papanicolaou-stained and unstained slides. Antigen retrieval offered no advantage in this study.

Hybrid tumors or salivary gland tumors sharing common differentiation pathways? Reexamining adenoid cystic and epithelial-myoepithelial carcinomas.

Three adenoid cystic carcinomas and two epithelial-myoepithelial carcinomas, which focally shared common histologic features, were studied to examine the common differentiation pathways manifested by these tumors and to discuss criteria for hybrid salivary gland tumors. Regions of the adenoid cystic carcinomas had cellular features ranging from simple clear cell change of basal/myoepithelial cells to combined clear cells and prominent ductal structures mimicking epithelial-myoepithelial carcinoma. Conversely, two epithelial-myoepithelial carcinomas had adenoid cystic carcinoma-like regions caused by the formation of "pseudocysts"; this resulted in a focal cribriform pattern. Electron microscopy of two additional but typical epithelial-myoepithelial carcinomas revealed both excess basal lamina at the margins of cellular nests and widened intercellular spaces containing reduplicated basal lamina and accumulations of glycosaminoglycans; these ultrastructural features were identical to those seen in adenoid cystic carcinomas. The five current cases are not examples of hybrid tumors, but they demonstrate the effects of gene expression and the resulting differentiation of synthetic products and tumor cells that are generally restricted to one or the other of these two tumor types by as-yet-unknown means. To avoid misdiagnosis and its prognostic implications, adenoid cystic carcinoma-like regions in epithelial-myoepithelial carcinoma and epithelial-myoepithelial-like regions in adenoid cystic carcinoma should be recognized simply as anomalous differentiation.

Fine needle aspiration cytology of pleomorphic lobular carcinoma of the breast. Duct carcinoma as a diagnostic pitfall.

Pleomorphic lobular carcinoma (PLC) of the breast is a subtype of lobular carcinoma of the breast that is well recognized in the surgical pathology literature. Fine needle aspiration (FNA) recognition of this subtype is important, for the subtype characteristically pursues an aggressive clinical course as compared to the classic lobular carcinoma of the breast. The cytologic literature on this entity is nonexistent. We describe the FNA findings in a series of four cases of PLC diagnosed retrospectively, discuss the cytologic features that are useful in the recognition of this entity and the diagnostic pitfalls, and propose classifying these tumors as a high (poor) nuclear grade variant of lobular carcinoma, analogous to the grading scheme in use for aggressive ductal carcinomas.

Fine needle aspiration cytology of lactating adenoma of the breast. A comparative light microscopic and morphometric study.

Six cases of lactating adenoma of the female breast diagnosed by fine needle aspiration (FNA) were reviewed. The FNA cytologic diagnostic features included a usually moderately cellular aspirate with an abundant foamy background material, intact epithelial lobules or acini and small groups and solitary epithelial cells that contained uniform nuclei, fine chromatin and prominent nucleoli. When present, the cytoplasm was finely vacuolated or wispy; many nuclei appeared stripped of their cytoplasm. These features were compared light microscopically with the cytopathologic features of six cases of invasive well-differentiated ductal adenocarcinoma, seven cases of invasive lobular carcinoma, one case of granulocytic sarcoma and one case of primary histiocytic lymphoma of the breast. In addition, cytomorphometric analysis demonstrated no statistically significant differences in the nuclear areas of lactating adenoma as compared with those of well-differentiated ductal carcinoma and lobular carcinoma.

Salivary duct carcinoma.

Twelve cases of salivary duct carcinoma were examined clinically, pathologically and by flow cytometry to quantify their histological features as well as attempt to identify factors predictive of patient outcome. All of the tumours arose in the parotid gland. Eight of the twelve patients were male. Four patients died of disease (median survival 12.5 months); three are alive with disease; and five are alive with no evidence of disease (mean follow-up of 50 months). Two tumours arose in a pre-existing pleomorphic adenoma. Positive lymph nodes were present in eight of ten patients sampled; patients with two or more positive lymph nodes tended to die of their disease or be alive with metastases. Comedo necrosis, perineural invasion and vascular invasion were common findings by light microscopy. Ten of the twelve tumours were aneuploid. Neither clinical stage, tumour size, aneuploidy nor histological features correlated with patient outcome. This study confirms the aggressive nature of salivary duct carcinoma.

Capillary versus aspiration biopsy: effect of needle size and length on the cytopathological specimen quality.

PURPOSE: To test the value of the nonaspiration, or capillary, biopsy technique by experimental comparison with the conventional fine-needle aspiration technique using various needle gauges and lengths. METHODS: On fresh hepatic and renal tissue from five autopsies, multiple biopsy specimens were taken with 20, 22, and 23-gauge Chiba needles of 5, 10, 15, and 20-cm length, using the aspiration technique and the capillary technique. The resultant specimens were graded on the basis of a grading scheme by a cytopathologist who was blinded to the biopsy technique. RESULTS: The capillary technique obtained less background blood or clot which could obscure diagnostic tissue, although not significantly different from the aspiration technique (p = 0.2). However, for the amount of cellular material obtained, retention of appropriate architecture, and mean score, the capillary technique performed statistically worse than aspiration biopsy (p < 0.01). In addition, with decreasing needle caliber (increasing needle gauge) and increasing length, the capillary biopsy was inferior to the aspiration biopsy. CONCLUSION: The capillary biopsy technique is inferior to the aspiration technique according to our study. When the capillary technique is to be applied, preference should be given to larger caliber, shorter needles.

Heterogeneity of salivary gland tumors studied by flow cytometry.

Intratumor DNA heterogeneity was investigated by flow cytometric analysis of multiple samples taken from different sites of 8 benign and 16 malignant primarily resected salivary gland tumors. All benign tumors had diploid DNA content. The overall incidence of DNA diploidy in 16 malignant cases examined was 50%. Intratumor differences in DNA ploidy were observed in four malignant tumors (25%); 2 of these 4 heterogeneous tumors contained both aneuploid and diploid cell clones. The remaining 12 tumors showed a homogeneous DNA content in the different specimens; 8 were diploid, 3 aneuploid, and 1 was polypoid. The DNA nondiploid tumors were clinically more advanced than the DNA diploid ones (p < 0.01). The tumor proliferation rate (fraction of cells in S-phase) was higher in DNA nondiploid samples than in diploid ones (p < 0.01). The DNA nondiploid tumors seemed to recur more often than DNA diploid ones did. The data emphasize the usefulness of DNA measurements for the characterization of malignant salivary gland tumors but also the importance of adequate sampling in assessing their DNA ploidy.

Percutaneous biopsy of the liver and kidney by using coaxial technique: adequacy of the specimen obtained with three different needles in vitro.

OBJECTIVE: The coaxial biopsy technique was evaluated with respect to the quality of specimens obtained from the liver and kidneys in vitro on sequential biopsies at the same site with each of three different biopsy needles. MATERIALS AND METHODS: For each of three different biopsy needles (aspiration 18-gauge Chiba, 18-gauge Sure-Cut, and 18-gauge Biopty), 30 sites (15 liver, 15 kidney) were selected for in vitro coaxial biopsy. At each site, an introducer was placed, through which three sequential biopsies were done. Blinded histopathologic analysis was used to grade the quality of specimens on a scale from 0 (no tissue) to 3 (best) for three criteria: adequacy of tissue for diagnosis, tissue fragmentation, and crush artifact. The overall score was the sum of the scores for the three individual criteria and ranged from 0 (no tissue) to 9 (best). RESULTS: Using an 18-gauge Chiba needle and coaxial technique, we found no significant reduction in specimen quality when we did multiple aspiration biopsies at the same site. However, no tissue was obtained (zero biopsy) from a large number of aspiration biopsies done with the Chiba needle, ranging from 24 of 30 for the first biopsy to 17 of 30 for the third biopsy. Specimen quality was reduced somewhat between the first and third biopsies when the 18-gauge Sure-Cut and Biopty needles were used. With the Sure-Cut needle, this reduction in quality was significant (p = .009) and was primarily related to increased tissue fragmentation and crushing. The reduction in quality with multiple biopsy attempts was less severe with the Biopty needle/gun. Although the mean score decreased from 6.6 for the first biopsy to 5.5 for the third biopsy, this reduction was not significant (p = .06). In addition, the Biopty gun, unlike the other two needles, had few zero biopsies. CONCLUSION: The use of a coaxial technique with an 18-gauge Biopty needle enables collection of a large amount of high-quality tissue for histopathologic analysis with a minimum number of failed biopsies as compared with the 18-gauge Chiba needle and the 18-gauge Sure-Cut needle.

Dopamine-secreting glomus vagale: a case report and histopathologic correlation.

BACKGROUND: Catecholamine secretion by head and neck paragangliomas is uncommon. Dopamine secretion by these tumors has not routinely been assessed. This case report describes a dopamine-secreting glomus vagale and evaluates seven other paragangliomas immunohistochemically for their ability to synthesize dopamine. METHODS: Light microscopic and immunohistochemical studies were performed on eight tumors, and biochemical testing for serum/urine catecholamines was performed on two patients. RESULTS: One patient (case report) had elevated serum dopamine which corrected following surgery. Five tumors stained strongly positive for the presence of tyrosine hydroxylase, the critical enzyme in the biosynthesis of dopamine. CONCLUSION: This case report describes the ability of a glomus vagale to secrete dopamine. Other paragangliomas express the enzymatic machinery necessary to begin catecholamine synthesis. Now that dopamine is routinely screened during catecholamine determination, other cases may be identified.