Cholangiocarcinoma: A diagnostic dilemma on cytology.

BACKGROUND: Cholangiocarcinoma is a relatively rare form of adenocarcinoma which may resemble adenocarcinoma of pancreatobiliary origin or adenocarcinomas from many other sites in the body. As a result, its diagnosis relies mainly on clinical history and morphology. CASE: A 64-year-old male with cirrhosis and worsening liver failure underwent fine needle aspiration of a radiologically detected liver mass. Cytological material showed a monomorphic population of cells arranged singly and in clusters, reminiscent of a neuroendocrine tumour (NET). Cell block morphology added to the diagnostic dilemma by showing a delicate vasculature among the tumour cells. Immunohistochemistry on the cell block revealed that cells were positive for CK7 and CK19 and negative for synaptophysin and chromogranin, thereby pointing towards a pancreatobiliary origin for the tumour and excluding an NET. CONCLUSION: In the case of liver aspirates, even when encountering confusing morphological entities, it is imperative to keep in mind the possibility of a rare neoplasm such as cholangiocarcinoma. In the absence of core needle biopsy, cell block sections prepared from aspirated material can provide appreciable immunohistochemistry results to resolve the diagnostic dilemma.

Bone Healing and Hormonal Bioassay in Patients with Long-Bone Fractures and Concomitant Head Injury.

OBJECTIVE: The aim of this study is to investigate healing of fractures in patients with concomitant head injuries and to measure blood hormone levels to elucidate the mechanism of a possible accelerated osteogenesis. MATERIALS AND METHODS: One hundred and sixty-two patients were included in this study and divided into 3 cohorts: group A with head injuries only (n = 52); group B with head injuries as well as long-bone fractures (n = 50); group C with long-bone fractures only (n = 60). Fracture-healing parameters including time of appearance and thickness of the bridging callus, and blood hormonal assays were measured and compared using Student's t test. RESULTS: The mean time to healing was significantly lower in cohort B (6.9 ± 2.9 weeks) than C (22.4 ± 8.7 weeks; p = 0.001). The mean thickness of the healing callus was significantly higher in cohort B (26.3 ± 9.7 mm) than C (8.1 ± 5.9 mm; p = 0.002). The mean healing rate was also higher in cohort B (4.5 ± 2.3 mm/week) than C (0.38 ± 0.21 mm/week; p = 0.001). Blood hormonal assays in group B showed higher values of parathyroid hormone and growth hormone than in group C. However, adrenaline and noradrenaline values were lower in group B than in group C at all measured time intervals, and correspondingly leptin was lower in all groups (p = 0.001). Corticosteroid values were normal in group B compared to slightly higher values in group C, also at all measured time intervals. CONCLUSION: In this study, healing of fractures in patients with concomitant head injuries was accelerated, thereby indicating an involvement of a combined neurohormonal mechanism.

A model to predict prostate cancer after atypical findings in initial prostate needle biopsy.

PURPOSE: Atypical small acinar proliferation can occur alone or with high grade prostatic intraepithelial neoplasia in either a discontinuous or contiguous pattern in a prostate needle biopsy. We assessed whether different subgroups of atypical small acinar proliferation and high grade prostatic intraepithelial neoplasia denote a differing risk of detecting subsequent prostate cancer. MATERIALS AND METHODS: We reviewed the pathological findings in 12,304 men who underwent initial prostatic needle biopsy during May 1999 to June 2007. Patients were included in the study if the initial diagnosis was atypical small acinar proliferation alone or combined with high grade prostatic intraepithelial neoplasia, or a benign diagnosis, and if followup prostatic needle biopsy was done. RESULTS: Prostate cancer developed in 22%, 27% and 49% of patients in the benign, high grade prostatic intraepithelial neoplasia and atypical small acinar proliferation groups, respectively (p <0.0005). In all subgroups there was a 35% to 57% rate of prostate cancer detection. The prostate cancer risk increased in the atypical small acinar proliferation subgroups according to the extent of high grade prostatic intraepithelial neoplasia in the initial sample, with atypical small acinar proliferation associated with multifocal high grade prostatic intraepithelial neoplasia carrying a 71% prostate cancer risk. CONCLUSIONS: Atypical small acinar proliferation combined with high grade prostatic intraepithelial neoplasia, particularly when associated with multifocal high grade prostatic intraepithelial neoplasia, is associated with a significant risk of prostate cancer detection on followup biopsy.

Pathological features of prostate cancer in men treated with robot-assisted radical prostatectomy in the Middle East.

Little is known about the pathological features of radical prostatectomy among men living in the Middle East. Although prostate cancer became the most common malignancy among males in some countries in the Middle East, the incidence is much lower compared to western populations. The aim of this study is to analyze pathological features and biochemical recurrence in men who underwent robotic-assisted radical prostatectomy (RARP) in Kuwait. The data on all RARP cases performed by a uro-oncologist (SA) were recorded. A comprehensive database was collected, including demographic, clinical, and pathological data. Between February 2014 and November 2019, 65 RARP cases were performed out of a total of 200 robotic urological procedures. The median follow-up was 41.5 months [inter quartile range (IQR) 27.6-52.7]. Eleven (17%) complications occurred in 7 patients, 64% were early (< 30 days post-operatively) and minor (Clavien I-II). Thirty-five (54%) patients had ≥ pT3 disease. Overall, 12 (18%) patients had a positive surgical margin (PSM), and all had ≥ pT3 disease. Potency and continence rates at 12 months were 82% and 97%, respectively. The mean and SD of the hospital stay were 2.7 ± 1.1 days. Biochemical recurrence (BCR) rate was 10%. Men with prostatic adenocarcinoma treated with RARP in Kuwait show a high incidence of pT3 disease. PSM and BCR rates were similar to multiple reports in the literature. To our knowledge, this is the first report of RARP pathological outcomes in the gulf cooperation council (GCC) region of the Middle East.

Metastatic medullary thyroid carcinoma to the breast in a patient with combined medullary and papillary carcinoma of thyroid--a case report.

We report the fine-needle aspiration cytology of a case of medullary thyroid carcinoma (MTC) metastatic to the breast in a 66-year old female within two years of diagnosis of the thyroid tumor. The aspirate of the breast metastases revealed a plasmacytoid population of cells in loose clusters and singly with mild to moderate pleomorphism. Nuclear groves and occasional intranuclear cytoplasmic inclusions were seen. The cells stained positive for calcitonin and negative for thyroglobulin. Use of immunocytochemical methods proved useful to diagnose metastasis which was essential in planning treatment. Cases of metastatic MTC to the breast diagnosed on fine-needle aspirates reported in the literature are reviewed.

Papillary thyroid carcinoma: how much should the surgeon read from fine needle aspiration cytology reports?

OBJECTIVE: During routine fine needle aspiration cytodiagnosis of papillary thyroid carcinoma (PTC), a number of cases are diagnosed as suspicious; or it is suggested that PTC or a neoplasm be ruled out by histopathology. Since these diagnostic labels are likely to put the clinicians in a difficult situation while planning the management, this study aims to find out how much the surgeon should read from these reports. MATERIALS AND METHODS: The patients were divided into two groups. Group A included 38 cases diagnosed as PTC or suspicious of PTC. Group B included 40 cases in which it was suggested that PTC/a neoplasm to be ruled out and non-neoplastic lesions with one or more cytologic features of PTC. The two groups were compared with clinical, imaging and cytomorphologic features. RESULTS: A significant difference was observed with respect to age between Group A and Group B (P<0.001). The frequency of the following five cytologic features was significantly higher in Group A: papillary formation (P<0.001), psammoma bodies (P=0.054), fine nuclear chromatin (P=0.010), frequent nuclear grooves (P<0.001) and intra-nuclear cytoplasmic inclusion (P<0.001). Three or more of the five cytologic features were also reported in significantly higher number of Group A cases (P<0.001). Majority (81.8%) of the cases with subsequent histology in Group A were confirmed as PTC as opposed to 7.7% in Group B (P<0.001). CONCLUSIONS: Thus, cases with definitive cytodiagnosis of PTC and suggestive of PTC (Group A) should be taken much more seriously by the surgeons as compared to Group B cases.

Cytokeratin positivity in myxopapillary ependymoma--a potential diagnostic pitfall.

BACKGROUND: Myxopapillary ependymomas (MPE) occur in the filum terminale of the spinal cord, but also present in extra-spinal locations such as subcutaneous tissue and brain. They are slow growing grade I gliomas. Areas of solid growth pattern with aggregates of cells with "epithelioid morphology" seen in MPE can mimic metastatic carcinoma. The presence of occasional cells with clear cytoplasm and morphology can resemble Chordoma. Diagnosis can be missed due to these morphological similarities, which could affect patient management and hence, long term survival. CASE PRESENTATION: We describe two cases of MPE with cytokeratin (AE1 AE3, CAM 5.2, Cytokeratin 7 and cytokeratin 20) expression. CONCLUSION: MPE can be positive for Cytokeratins (CAM 5.2, AE1 AE3, CK7) and focally for EMA, which could be misdiagnosed as metastatic carcinoma. In cases demonstrating epithelioid and clear cell morphology, the diagnosis of MPE should be made in conjunction with histology, proper immunohistochemical profile which includes co-expression of GFAP, S-100 protein and epithelial markers, radiologic findings and site. It is important to be aware of the cytokeratin profile in MPE to avoid erroneous diagnosis with other tumour entities.

Telomere attrition in isolated high-grade prostatic intraepithelial neoplasia and surrounding stroma is predictive of prostate cancer.

The causes of early genomic events underlying the development of prostate cancer (CaP) remain unclear. The onset of chromosomal instability is likely to facilitate the formation of crucial genomic aberrations both in the precursor lesion high-grade prostatic intraepithelial neoplasia (HPIN) and in CaP. Instability generated by telomere attrition is one potential mechanism that could initiate chromosomal rearrangements. In this study, normalized telomere length variation was examined in a cohort of 68 men without CaP who had HPIN only on prostatic biopsies. Multiple significant associations between telomere attrition and eventual diagnosis of CaP in the HPIN and in the surrounding stroma were found. Kaplan-Meier analysis of telomere length demonstrated a significantly increased risk for the development of cancer with short telomeres in the surrounding stroma [P = .035; hazard ratio (HR) = 2.12; 95% confidence interval (95% CI) = 0.231-0.956], and a trend for HPIN itself (P = .126; HR = 1.72; 95% CI = 0.287-1.168). Cox regression analysis also demonstrated significance between the time from the original biopsy to the diagnosis of cancer and telomere length in HPIN and in the surrounding stroma. These analyses showed significance, both alone and in combination with baseline prostate-specific antigen, and lend support to the hypothesis that telomere attrition in prostatic preneoplasia may be fundamental to the generation of chromosomal instability and to the emergence of CaP.