Guideline No. 449: Diagnosis and Impact of Endometriosis - A Canadian Guideline.

OBJECTIVE: To provide a contemporary approach to the understanding of the impact and methods for the diagnosis of endometriosis in Canada. TARGET POPULATION: Individuals, families, communities, health care providers, and health care administrators who are affected by, care for patients with, or manage delivery of services for endometriosis. OPTIONS: The diagnosis of endometriosis is facilitated by a detailed history, examination, and imaging tests with providers who are experienced in endometriosis care. Surgical evaluation with pathology confirms a diagnosis of endometriosis; however, it is not required for those whose diagnosis was confirmed with imaging. OUTCOMES: There is a need to address earlier recognition of endometriosis to facilitate timely access to care and support. Education directed at the public, affected individuals and families, health care providers, and health care administrators are essential to reduce delays in diagnosis and treatment. BENEFITS, HARMS, AND COSTS: Increased awareness and education about the impact and approach to diagnosis may support timely access to care for patients and families affected by endometriosis. Earlier and appropriate care may support a reduced health care system burden; however, improved clinical evaluation may require initial investments. EVIDENCE: Each section was reviewed with a unique search strategy representative of the evidence available in the literature related to the area of focus. The literature searches for each section of this guideline are listed in Appendix A and include information from published systematic reviews described in the text. VALIDATION METHODS: The recommendations were developed following two rounds of review by a national expert panel through an iterative 2-year consensus process. Further details on the process are shared in Appendix B. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix C (Table C1 for definitions and Table C2 for interpretations of strong and conditional recommendations). INTENDED AUDIENCE: This guideline is intended to support health care providers and policymakers involved in the care of those impacted by endometriosis and the systems required to support them. TWEETABLE ABSTRACT: Endometriosis impact and diagnosis updated guidelines for Canadian health care providers and policymakers. SUMMARY STATEMENTS: RECOMMENDATIONS.

Primary epithelioid angiosarcoma of the mediastinum, cytomorphologic features of a rare entity-A case report and literature review.

Epithelioid angiosarcoma (EA) is a highly aggressive vascular neoplasm. Primary mediastinal EA is extremely rare with only few cases reported in the English literature. We herein present a case of a 78-year-old patient, who was found to have a right superior mediastinal mass associated with mediastinal and hilar lymphadenopathy. Endobronchial ultrasound guided fine needle aspiration cytology of a station 4R lymph node revealed a cellular, discohesive malignant neoplasm displaying primarily epithelioid morphology with occasional spindled, plasmacytoid, and tumor giant cells. The tumor cells had ample eosinophilic cytoplasm with pleomorphic nuclei and prominent nucleoli. Vasoformative features were noted, exemplified by widespread cytoplasmic vacuoles containing neutrophils and rare red blood cells (hemophagocytosis) and vascular channels identified solely in the cell block. By immunohistochemistry, the tumor cells stained strongly positive for vimentin, positive for ERG, CD-31, FLI-1, and focally positive for pan-cytokeratin. The cytomorphological features and immunostaining patterns were diagnostic of EA. No history of malignancy was reported, and no other lesions were identified on imaging. The diagnosis of primary mediastinal EA on cytology and small biopsy specimens may be challenging due to the rarity of this tumor, limited diagnostic material, and overlapping morphologic features with other entities in the differential diagnosis. A high index of suspicion, especially in cases with vasoformative features, and utilization of ancillary studies can help establish the diagnosis.

Role of ThinPrep liquid-based cytology in evaluation of the endocervical canal in patients with abnormal cervical screening.

INTRODUCTION: Endocervical sampling is frequently used as an adjunct to colposcopy. Few studies address the role of endocervical brushing (ECB) with liquid-based cytology (LBC) for evaluation of the endocervical canal. We assessed the roles of ThinPrep (TP) LBC of ECB specimens and cell blocks (CBs). MATERIALS AND METHODS: Pathology archives were searched for ECB specimens from 2010-2015. Preceding Papanicolaou test interpretation, human papillomavirus status, concurrent and follow-up surgical specimens, and ECB diagnoses were recorded. CB cellularity, when available, was scored on a scale of 0 to 4. The cellularity of the TP and CBs was compared. RESULTS: Of 365 ECB cases, 6 (1.6%) were insufficient for diagnosis, compared with a 5% rate for endocervical curettings. Eleven ECB cases (3%) showed low cellularity. Of the 241 (66%) cases with concurrent biopsies, the ECB diagnosis agreed with the biopsy diagnosis (within 1 grade) in 198 (82%) cases. In 9 (2.5%) cases, ECB was the only means of diagnosis of a high-grade squamous intraepithelial lesion / adenocarcinoma in situ confirmed on follow-up. Compared with TP LBC, the CBs (performed in 84 [23%] of cases) were of greater cellularity in 30 (42%) and of equal cellularity in 17 (24%). None of the CBs showed an additional epithelial abnormality missed in TP LBC. CONCLUSIONS: TP LBC is capable of detecting endocervical epithelial abnormalities and may be used as a substitute for endocervical curettings. Performing a CB did not lead to detection of additional abnormalities, although it complemented TP findings and facilitates the performance of ancillary studies.

Anaplastic lymphoma kinase positive large B-cell lymphoma: Literature review and report of an endoscopic fine needle aspiration case with tigroid backgrounds mimicking seminoma.

Anaplastic lymphoma kinase-positive large B-cell lymphoma (ALK+ LBCL) is a rare distinct type of non-Hodgkin's lymphoma that arises in association with alterations of the ALK gene. This distinct disease entity is typically associated with an aggressive clinical course and appears in light microscopic preparations as a monomorphic population of large, immunoblast-like cells. In this report, we describe a case of ALK+ LBCL diagnosed by transgastric endoscopic ultrasound-guided fine needle aspiration (EUS FNA) of splenic hilar lymph nodes. Modified Giemsa stained direct smears from the FNA sample demonstrated large lesional cells with foamy cytoplasm and macronucleoli admixed with small lymphocytes in tigroid backgrounds, mimicking the cytologic appearance of seminoma. Ancillary immunohistochemical studies subsequently confirmed the diagnosis of ALK+ LBCL with the lesional cells being immunoreactive for CD138, VS38c, MUM1, ALK1, and lambda light chain. The cohesiveness of the cells, the cellular morphology, and the tigroid backgrounds were all pitfalls for accurate diagnosis of this rare specific type of lymphoid malignancy by cytology. To our knowledge this is the first case report detailing the diagnosis of ALK+ LBCL by EUS FNA and the first report describing a glycogen-rich tigroid background in direct FNA smears. Establishing a refined diagnosis in cases of this rare form of LBCL is necessary, as therapies targeting ALK may be of value in clinical management. Diagn. Cytopathol. 2017;45:148-155. © 2016 Wiley Periodicals, Inc.

Pathology correlates of a Papanicolaou diagnosis of low-grade squamous intraepithelial lesion, cannot exclude high-grade squamous intraepithelial lesion.

BACKGROUND: The objective of this study was to compare findings after a cytologic report of low-grade squamous intraepithelial lesion, cannot exclude high-grade squamous intraepithelial lesion (LSIL-H) with findings after a report of low-grade squamous intraepithelial lesion (LSIL). METHODS: A review of patient records revealed that 312 women had cytologic findings of LSIL-H, and 324 consecutive women in a comparison group had cytologic findings of LSIL during 2005. Findings over 6 months after diagnosis were retrieved and analyzed using chi-square tests, Fisher exact tests, and independent group t tests. RESULT: Histology was available for 194 of 312 women (64%) with LSIL-H and for 184 of 324 women (57%) with LSIL. Of these, 47 of 194 women (24%) with LSIL-H had grade 2 cervical intraepithelial neoplasia or greater (CIN2+) versus 13 of 184 women (7%) with LSIL (P < .0001). No cancers were identified. High-grade SIL cytology was reported in 2 of 105 women who had LSIL (2%) and in 4 of 93 women who had LSIL-H (4%). Women with LSIL-H who were positive for CIN2+ were younger than those without CIN2+ (25 years vs 30 years; P = .0067) CONCLUSIONS: Clinicians whose laboratories report LSIL-H should manage women who have LSIL-H with colposcopy, whereas only serial cytologic surveillance is required after a report of LSIL.