Malignant biphasic pleural mesothelioma metastatic to the liver diagnosed by fine-needle aspiration.

As malignant pleural mesotheliomas are most often rapidly fatal, distant metastases are rarely detected. Here, we report a unique case in which the diagnosis of metastatic pleural mesothelioma was made via cytologic examination of a fine-needle aspiration (FNA) of the liver. Recognition of the cytomorphologic features inherent to mesothelioma cells on FNA material may become important for proper patient management. To the best of our knowledge, the diagnosis of malignant pleural mesothelioma metastatic to the liver made by FNA has not been previously documented.

Ductal lavage in the high-risk patient.

BACKGROUND: [corrected] This analysis was conducted in a single-surgeon clinical practice to evaluate the utility and practicality of performing ductal lavage in a population determined to be at high risk for breast cancer. METHODS: One hundred twenty patients with negative mammograms and/or negative breast examinations had nipple aspiration and ductal lavage performed by a single surgeon. All were at high risk either according to Gail risk score, a previous breast carcinoma, or nipple discharge. RESULTS: One hundred twenty patients underwent nipple aspiration. Thirty-two did not undergo lavage: 29 had no fluid, and 3 had unsuccessful cannulation. Eighty-eight underwent lavage: 15 had insufficient epithelial content, 51 had benign cytology, and 22 had abnormal cells. Of the 22, 20 had mild atypia, 1 had marked atypia, and 1 had malignant cells. CONCLUSIONS: Ductal lavage can be done in a surgical practice and can stratify risk for the individual patient. This is important to both patient and surgeon in formulating a treatment plan based on objective cytologic criteria.

Cytomorphology and immunohistochemistry of a recurrent clear cell odontogenic carcinoma with molecular analysis: A case report with review of literature.

Clear cell odontogenic carcinoma (CCOC) is a rare, odontogenic tumor of the jaws with mandibular involvement usually present in sixth decade of life with female preponderance. It is classified as a malignant tumor of odontogenic origin in 2005 by the World Health Organization because of its aggressive and destructive growth capacity and potential to metastasize. It needs to be distinguished from other primary and metastatic clear cell tumors of the oral and maxillofacial region. Recently, CCOCs have been noted to harbor a Ewing sarcoma breakpoint region 1 gene RNA-binding protein 1 (EWSR1) and activating transcription factor (ATF) gene translocation. To date, cytologic features of only one case have been reported in the literature. We report an additional case of 55-year-old woman with enlarging mass in the left mandible. This report describes cytologic and immunohistochemical features of CCOC with positive EWSR1 gene rearrangements by fluorescence in situ hybridization (FISH). As diagnosis of CCOC is challenging on fine-needle aspiration, immunohistochemistry and FISH analysis are very useful diagnostic tool in clear cell lesions of mandible.

Ductal lavage using medically aseptic technique in women at high risk for breast cancer.

Ductal lavage of the breast is a minimally invasive procedure used to collect epithelial cells from the lumen of the ductolobular system for cytologic analysis. The purpose of this study was to determine the safety of using an aseptic technique in performing ductal lavage. The study included 114 consecutive patients at high risk for breast cancer with clinically negative mammograms and no palpable masses. Ductal lavage could not be performed on 32 of the 114 patients (28%): 26 because nipple aspirate fluid could not be obtained, and 6 because a fluid-yielding duct could not be cannulated. Ductal lavage was successfully performed on 82 patients (72%). Local anesthetic cream was used on the nipple area and local anesthetic was infused into each duct. The nipple, the cup of the nipple aspirator device, and any dilator tools were cleansed with alcohol before use. Separate sterile microcatheters were used for each duct. Sterile saline solution was used for the infusions. No patient reported any symptoms indicating infection after lavage. Cytologic analysis from the 82 lavage cases showed 45 benign cells (55%), 17 cases of mild atypia (21%), 1 case of marked atypia, and 1 case with malignant cells. Eighteen samples (22%) had inadequate cellularity for medical diagnosis. The results of the study indicate that an aseptic technique is safe and appropriate for ductal lavage of the breast.

Fine-needle aspiration of clinically suspicious palpable breast masses with histopathologic correlation.

BACKGROUND: The purpose of this study was to compare the diagnostic accuracy of fine-needle aspiration (FNA) of clinically suspicious palpable breast masses in women younger and older than 40 years of age. METHODS: All women who had FNA biopsy with subsequent tissue biopsy were included. The cytologic diagnoses were classified into three groups: malignant, suspicious, or benign. Histopathologic correlation was based on either a needle core biopsy, an excisional biopsy, or a mastectomy specimen. RESULTS: A total of 1,158 fine-needle aspirations performed between 1982 and 2000, on women being evaluated for a clinically palpable breast mass were included in the study. The patients were divided into two groups: group I consisted of 231 patients aged 40 years and younger, and group II consisted of 927 patients aged 41 years and older. In group I there were 117 (51%) malignant FNA diagnoses, and only 1 (1%) false-positive case, subsequently diagnosed on histopathologic material as an atypical papillomatosis. There were 20 (9%) cases diagnosed as suspicious on FNA. On histopathology 10 were malignant, and 10 were benign. Of the 91 (39%) cases interpreted as benign, only 1 (1%) was a false negative. In group II, which comprised 927 patients, there were 693 (74%) malignant FNA diagnoses, and 3 (less than 1%) false-positive cases, which on follow-up histopathologic examination revealed 2 atypical ductal hyperplasias and 1 atypical papilloma. There were 90 (10%) cases diagnosed as suspicious on FNA. On histopathology, 68 were malignant and 22 were benign. Of the 131 (14%) lesions interpreted as benign, there were 18 false-negative cases (14%), which included 17 infiltrating carcinomas and 1 ductal carcinoma in-situ. Twelve (1%) of the cases were inadequate for the study. CONCLUSIONS: The sensitivity, specificity, and positive predictive values were remarkably high and comparable in both groups: group I had 99% sensitivity, 99% positive predictive value, 99% specificity, and 99% negative predictive value; and group II had 98% sensitivity, 97% specificity, 99% positive predictive value, and 86% negative predictive value. The overall rate of false-positive (less than 1%) and false-negative cases (9%) is comparable with published literature. Suspicious cases should be further evaluated, as our study revealed more than 50% to be malignant. The incidence of malignancy in patients presenting with a clinically palpable breast mass with follow-up biopsy was 51% in patients aged 40 years and younger and 74% in patients aged 41 years and older. Fine-needle aspiration is an excellent diagnostic tool in assessing clinically palpable breast masses.

Brush cytology of the biliary tract: retrospective study of 278 cases with histopathologic correlation.

Bile aspiration during endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography has been used as a diagnostic tool in the evaluations of pancreatic and biliary tree strictures for the last two decades. However, recently biliary tract brush cytology has become the method of choice in evaluating pancreatic/biliary tract abnormalities. The aim of this study was to evaluate the accuracy of pancreatobiliary lesions by an endobiliary cytotechnique. From 1993-1999, 278 pancreatobiliary brushings were performed at our institutions. Cytologic material was air-dried for Diff-Quik stain or fixed in ethanol for Papanicolaou staining. The cytologic diagnoses were classified in three categories: 1) benign, 2) atypical/suspicious, or 3) malignant. Subsequent surgical biopsy was available in 87 (31%) patients. There were 150 males and 128 females with a mean age of 63 yr (range 22-97); 167 (60%) were benign cases. Follow-up surgical material was available in 39 cases, seven of which showed adenocarcinoma; 67 of all cases (24%) were atypical/suspicious cases. Follow-up surgical material was available in 31 cases, 17 (55%) of which showed adenocarcinoma; 32 cases (12%) were malignant cases. Follow-up surgical material was available in 15 cases. All 15 cases were in agreement with the cytologic diagnosis. Twelve (4%) cases were unsatisfactory for cytologic examination. Follow-up surgical material was available in two cases. One case showed mucinous cystadenoma of the pancreas. The other case showed benign duct epithelium. Our study shows a sensitivity of 68% and a specificity of 100%. Of the atypical cases, 55% were malignant on follow-up biopsy. Brush cytology of pancreatobiliary strictures is the most widely used technique in the diagnosis of carcinoma, with a high degree of specificity.

Diagnostic role of fine-needle aspiration of pancreatic allograft to detect rejection.

The purpose of this study was to assess whether the same principles to evaluate renal transplant by fine-needle aspiration (FNA) for rejection could be applied to pancreatic allograft. Between 1996-1998, 25 ultrasound-guided FNAs on 13 patients with pancreatic allograft were performed and ThinPrep made. The percentage of lymphocytes, lymphoblasts, monocytes, eosinophils, plasma cells, immunoblasts, and macrophages were calculated. Simultaneous peripheral smear was obtained and "total corrected increment" score calculated. Subsequent core biopsy was available in six patients. A total of seven FNAs on three patients were inadequate because of insufficient epithelial cells. No evidence of rejection reported in nine patients was confirmed on biopsy in five patients. One patient reported as suspicious later showed rejection on biopsy. Thus, FNA may be used to monitor the graft status with faster turnaround times. Rejection may be a focal process and FNA may be used for sampling multiple sites. Cytologic diagnosis fairly accurately detects early rejection. Core biopsies are warranted in unsatisfactory specimens and when FNA is suspicious for rejection.

Anaplastic T large cell lymphoma diagnosed by exfoliative cytology in a post renal transplant patient.

In the last two decades posttransplant lymphoproliferative disorders (PTLDs) have been recognized as a complication of organ transplantation with immunosuppression. The reported incidence of PTLDs in renal transplant patients ranges between 0.3-3% (Birkeland et al., Transplantation 1999;67:876-881). In contrast to the reported incidence of PTLDs in post bone marrow transplant, it is 1% in HLA-matched recipients and up to 20% in HLA mismatched T-cell depleted bone marrow recipients (Curtis et al., Blood 1996;94:2208-2216). In cardiac transplant recipients the reported incidence of PTLDs is between 1.8-9.8 (Mihalov et al., Clin Transplant 1996;10:248-255). PTLDs are predominately extranodal. They have varied morphologic patterns and clonality, but almost all are associated with Epstein-Barr virus (EBV). The vast majority are of B cell lineage; only about 10% are of T-cell origin. We report a T-cell anaplastic large cell lymphoma (ALCL) presenting with bilateral pleural effusion and liver involvement in a renal transplant recipient.

Application of adjunct techniques in cytologic material in the diagnosis of rhabdomyosarcoma: case report and review of the literature.

A 4(1/2)-yr-old female presented with right-sided pleural effusion and a retroperitoneal mass. Cytologic analysis of the pleural fluid yielded malignant small round blue cells, which were noncohesive, 3-4 times the size of lymphocytes. The malignant cells had hyperchromatic, pleomorphic nuclei with moderate amounts of vacuolated cytoplasm. A few fiber-shaped cells were also seen. Immunostains for desmin, muscle-specific actin were positive; ultrastructural findings of thick and thin actin-myosin filaments confirmed the diagnosis of embryonal rhabdomyosarcoma. This case illustrates the importance of performing appropriate immunohistochemical stains and ultrastructural studies on cytological material to arrive at a definitive diagnosis.

Fine-needle aspiration of superficial and deeply seated lymph nodes on patients with and without a history of malignancy: review of 439 cases.

This study addresses the utility of fine-needle aspiration (FNA) in assessing lymphadenopathy in patients with and without a previous history of malignancy. We reviewed the FNAs of superficial and deeply seated lymph nodes performed at our institution over a period of 18 yr (1983-2001). Where applicable, we also reviewed and report here the results of subsequent surgical excisional biopsies. We analyzed data from 439 patients, who ranged in age from 1 to 90 yr. The neck and retroperitoneum were the most frequently sampled sites (47% and 25%, respectively). Among the 439 FNAs, adequate material was obtained in 421 cases (96%); the remaining 18 were unsatisfactory (4.1%). Malignant diagnoses were rendered in 330 cases (75% of 439), four were suspicious for lymphoma (0.9%), and 87 were read as reactive lymph nodes or granulomas (20%). The most common malignant cytologic diagnoses from these lymph node FNAs were adenocarcinoma, squamous cell carcinoma, and lymphoma. We compared results between two major groups: patients with a history of malignancy and those without. FNA showed malignancy in 87% of patients with a history of cancer and 41% without such a history. Thirty-three or 10% of patients with a history of malignancy were given a benign diagnosis and follow-up surgical excisional biopsies were performed in nine of these cases. Four of the nine showed low-grade lymphoma. Of the 18 non-diagnostic FNAs, nine came from patients with a history of malignancy and in six of these nine who had a follow-up surgical excisional biopsy the lymph nodes were positive for malignancy. Of the other nine, who had no history of malignancy, only two had follow-up biopsies and both of these were negative. Patients with a history of malignancy are more than twice as likely to show malignancy on lymph node FNA compared to those without such a history (87% vs. 41%). Knowing whether a patient has a history of malignancy provides the appropriate level of suspicion for ordering ancillary investigations or even recommending excisional biopsy for further evaluation.

Diagnostic role of fine-needle aspiration of bone lesions in patients with a previous history of malignancy.

At the present time fine-needle aspiration (FNA) is considered a routine diagnostic procedure in evaluating neoplastic vs. nonneoplastic lesions in many organs, with high sensitivity and specificity. The purpose of this study was to assess the utility of FNA in areas of diagnostic difficulty and its limitations in evaluating bone lesions in patients with a previous history of malignancy. From 1989 to 2000, 249 CT-guided FNAs of bone lesion were performed at our institutions; 187/249 (75.1%) patients had a previous history of malignancy. Aspirated material was air-dried for Diff-Quik stain or fixed in ethanol for Papanicolaou staining. Subsequent surgical tissue was available in 69/187 (36.9%) of the cases. There were 114 males and 73 females, ages 14-86 yr (mean, 64 yr). The primary tumor site was lung 49, genitourinary 46, breast 31, gastrointestinal 28, hematopoietic 26, soft tissue/skin 5, and thyroid 2. There were 125 FNAs of the vertebral spine, 19 from the pelvis, 11 from the ribs, 9 from the sternum, 5 from the femur, and 18 from miscellaneous bone sites. Out of 187, 166 (88.7%) were malignant aspirates confirming the patients' primary malignancies. The most common malignancy encountered was adenocarcinoma, 126/187 (67.4%). Surgical tissue was available for review in 69 patients and the results were in agreement with the FNAs diagnosis in all cases. Nine out of 187 (4.8%) cases were diagnosed as marrow elements on cytological material. These patients have been followed for 1-9 yr and have failed to reveal signs or symptoms of clinical recurrence. Three out of 187 (1.6%) cases showed osteomyelitis. Nine out of 187 (4.8%) were unsatisfactory specimens, with biopsy follow-up available in four cases, showing three metastatic tumors and one case of osteomyelitis. FNA of metastatic bone lesions is a major step in pretreatment diagnosis. On satisfactory specimens, the cytological diagnosis viewed in the clinical-radiological context proves to be similar to surgical diagnosis. FNA is an excellent technique with a high accuracy rate in assessing metastatic bone lesions.

Cytologic findings of acute leukemia in bronchoalveolar lavage fluid.

Bronchoalveolar lavage (BAL) is often performed in patients with acute leukemia developed with respiratory failure or pulmonary infiltrates. Patients usually undergo BAL to rule out infection. Occasionally, however, leukemic infiltrate may be detected. We present a series of 11 cases in which the diagnosis of leukemia was made on the BAL material. We retrospectively reviewed all BAL samples from January 1, 2006 to December 31, 2008. There were a total of 1,130 cases, of which 139 showed malignant cytology, including 10 with leukemia. Sixteen samples were unsatisfactory and 904 were benign, of which 32 had identifiable microorganisms. In additional to the 10 leukemia cases identified, two more were reviewed after the search criteria. The 12 patients (seven men, five women) ranged from 22 to 75 years old. All patients had previously biopsy-proven leukemia [two acute myelomonocytic leukemia, two acute promyelocytic leukemia, two acute myeloid leukemia (AML) with inv16, two therapy-related AML, one acute monocytic leukemia, one chronic myeloid leukemia in blast face, one AML with maturation, one myelodysplastic syndrome with excess blasts, and one large granular leukemia]. Four had a prior diagnosis of myelodysplastic syndrome. The time from initial diagnosis of leukemia to BAL ranged from 1 to 233 days, with 8 of 10 occurring within 8 days of diagnosis. Symptoms that prompted BAL included shortness of breath/hypoxia (8), fever (3), chest pain (2), and cough (2). Chest X-rays in all cases revealed opacities or consolidations mimicking an inflammatory process. Seven patients subsequently died, while three were alive, and, in remission, and two were lost to follow-up. The presence of a leukemic infiltrate can mimic infection. BAL is a relatively safe and useful diagnostic tool in this setting for differentiating a leukemic infiltrate from an infection/inflammatory infiltrate. The prognosis of patients with lung involvement of acute leukemia is poor.

Update on human polyomavirus BK nephropathy.

Polyomavirus BK (BKV) has ebeen identified as the main cause of polyomavirus-associated nephropathy, a major cause of renal allograft failure. Although BKV-associated nephropathy develops in only 2% to 5% of renal transplant recipients, its prognosis when present is very poor, with irreversible graft failure developing in 45% of affected patients. While the use of urine cytology for the detection of decoy cells has been in use for decades, other diagnostic modalities to detect BKV have emerged, including tissue biopsy, polymerase chain reaction, viral culture, and serology. Currently, there is no consensus regarding the laboratory technique best suited for clinical monitoring. This review article will discuss essential and clinical features of polyomavirus, followed by a discussion pertaining to the various diagnostic modalities that contribute to detecting polyomavirus-associated nephropathy.