Non-Seminomatous Germ Cell Tumor Presenting with Superior Vena Cava Syndrome.

BACKGROUND Primary mediastinal non-seminomatous germ cell tumors (NSGCTs) are aggressive and carry a poor five-year disease free survival rate even with aggressive treatment. We describe a young adult male with primary mediastinal NSGCT presenting with airway obstruction and superior vena cava syndrome (SVCS). CASE REPORT The patient presented with four weeks of nonproductive cough, weight loss, and right-sided pleuritic chest pain. Chest computed topography (CT) imaging demonstrated a right-sided mediastinal mass determined as a yolk sac tumor on biopsy. The patient underwent induction chemotherapy with etoposide and cisplatin for stage III NSGCT. In the interim, he developed SVCS warranting a second cycle of chemotherapy along with intravenous steroids, with notable improvement in symptoms. However, serial alpha-fetoprotein (AFP) measurements showed progressively increasing levels up to a maximum of 18,781 ng/mL indicating treatment failure. He is currently on salvage chemotherapy. CONCLUSIONS Obstruction of the SVC by external compression is often a manifestation of a malignant process in the thorax. SVCS is a medical emergency and occurs in 6% of patients with mediastinal GCTs. Historically, irradiation was initiated without a histologic diagnosis to relieve the life-threatening obstruction. However, newer data suggest that it is acceptable to defer therapy until a full diagnostic workup is completed. This case highlights the malignant nature of primary mediastinal NSGCTs. In addition, inasmuch as SVCS is dramatic in presentation, it is important to recognize that symptomatic obstruction often develops over weeks or longer. In a hemodynamically stable patient, an accurate histologic diagnosis prior to starting treatment is essential in guiding therapy.

The clinical impact of immediate on-site cytopathology evaluation during endoscopic ultrasound-guided fine needle aspiration of pancreatic masses: a prospective multicenter randomized controlled trial.

OBJECTIVES: Observational data on the impact of on-site cytopathology evaluation (OCE) during endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) of pancreatic masses have reported conflicting results. We aimed to compare the diagnostic yield of malignancy and proportion of inadequate specimens between patients undergoing EUS-FNA of pancreatic masses with and without OCE. METHODS: In this multicenter randomized controlled trial, consecutive patients with solid pancreatic mass underwent randomization for EUS-FNA with or without OCE. The number of FNA passes in the OCE+ arm was dictated by the on-site cytopathologist, whereas seven passes were performed in OCE- arm. EUS-FNA protocol was standardized, and slides were reviewed by cytopathologists using standardized criteria for cytologic characteristics and diagnosis. RESULTS: A total of 241 patients (121 OCE+, 120 OCE-) were included. There was no difference between the two groups in diagnostic yield of malignancy (OCE+ 75.2% vs. OCE- 71.6%, P=0.45) and proportion of inadequate specimens (9.8 vs. 13.3%, P=0.31). Procedures in OCE+ group required fewer EUS-FNA passes (median, OCE+ 4 vs. OCE- 7, P<0.0001). There was no significant difference between the two groups with regard to overall procedure time, adverse events, number of repeat procedures, costs (based on baseline cost-minimization analysis), and accuracy (using predefined criteria for final diagnosis of malignancy). There was no difference between the two groups with respect to cytologic characteristics of cellularity, bloodiness, number of cells/slide, and contamination. CONCLUSIONS: Results of this study demonstrated no significant difference in the diagnostic yield of malignancy, proportion of inadequate specimens, and accuracy in patients with pancreatic mass undergoing EUS-FNA with or without OCE.

Microphthalmia transcription factor immunohistochemistry for FNA biopsy of ocular malignant melanoma.

BACKGROUND: Microphthalmia transcription factor (MiTF) is a sensitive and specific immunohistochemistry (IHC) marker for malignant melanoma (MM) in surgical resections, but its utility in cytology specimens has not been extensively studied. METHODS: A search of the pathology database identified fine-needle aspiration biopsies signed out as MM or suspicious for MM (1998-2012). The final diagnosis and the IHC results were recorded, and all slides were re-reviewed. MiTF IHC (C5/D5 cocktail) was performed on alcohol-fixed, Papanicolaou-stained direct smears. Any amount of nuclear staining was considered positive. Staining was scored on a scale of 1 to 4 (1, 1%-24%; 2, 25%-49%; 3, 50%-74%; 4, 75%-100%). RESULTS: Two hundred seventy-four cases were diagnosed as MM, and 24 were diagnosed as suspicious for MM. IHC staining was performed for 25% (69 of 274) of the MM cases and for 33% (8 of 24) of the cases suspicious for MM. MiTF IHC of Papanicolaou slides was performed for 37% (101 of 274) of the MM cases (positive, 82% [83 of 101]; negative, 4% [4 of 101]; noncontributory, 14% [14 of 101]) and for 33% (8 of 24) of the cases suspicious for MM (positive, 38% [3 of 8]; noncontributory, 62% [5 of 8]). The majority of positive staining was scored as 3 or 4. The sensitivity of MiTF on Papanicolaou-stained slides was 95%. CONCLUSIONS: MiTF is a useful IHC stain for the evaluation of ocular MM, and it is effective when it is performed on alcohol-fixed, Papanicolaou-stained aspirate smears.

Correlation of liver and pancreas endoscopic ultrasonography-guided fine-needle aspiration biopsy in patients with a primary pancreatic lesion.

BACKGROUND: Endoscopic ultrasonography (EUS) is commonly used in the evaluation of pancreas masses, and when a liver lesion is visualized, it can undergo a fine-needle aspiration (FNA). This can provide diagnostic and staging information. The purpose of the study was to correlate the findings of patients who underwent EUS FNA biopsy of a pancreas lesion and a liver lesion during the same procedure. MATERIALS AND METHODS: The pathology database at Washington University Medical Center was searched for EUS FNA biopsy cases where biopsy of both the pancreas and liver were performed over a consecutive 10-year period (2003-2013). All pathology reports were reviewed, and clinical information and diagnostic results were recorded. RESULTS: A total of 102 cases were identified. For pancreas cases, 79.4% were malignant and for liver cases, 58.8% were malignant. In pancreas lesions categorized as suspicious for malignancy (9%), the liver biopsy provided a diagnosis of malignancy in 67% of cases. A malignant pancreatic cohort demonstrated a 62.9% liver malignancy. A malignant liver cohort corresponded to a malignant pancreas diagnosis in 86.6% of cases and a suspicious-malignant group of 98.3%. CONCLUSIONS: The 102 cases with concomitant EUS FNA biopsy of the pancreas and liver demonstrated the ability to provide a diagnosis of pancreas malignancy and correlate regional metastatic malignancy in the liver. In patients with a pancreas mass and in the appropriate clinical setting, a liver EUS FNA biopsy has the ability to provide a diagnosis of malignancy and demonstrate a high positive predictive value of malignancy in the pancreas (98.3%).

Improved efficacy of endobronchial ultrasound-guided fine-needle aspiration biopsy in comparison to endobronchial ultrasound-guided miniforceps biopsy.

OBJECTIVE: Endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA) cytology and EBUS-miniforceps biopsy (MFB) have emerged as less invasive tools for evaluating mediastinal lymph nodes and pulmonary lesions. The aim of this study is to compare the diagnostic yields of EBUS-FNA cytology to EBUS-MFB. STUDY DESIGN: A retrospective cohort study was performed by reviewing the database at our institution between December 12, 2010, and August 10, 2012. A total of 476 consecutive cases were identified. Of these, 227 patients had concurrent FNA and MFB taken during the procedure. The results and diagnostic yields of both techniques are calculated. RESULTS: Of the 476 cases, the mean age was 62 ± 14 years with 53% being males. In 453 of the total cases, the less invasive FNA technique alone produced enough diagnostic cytology material negating the need for concurrent MFB. Of these FNA cases, 280 were diagnosed as malignant neoplasms. The diagnostic yield of EBUS-FNA cytology was comparable to EBUS-MFB (95% FNA and 94% MFB). There were discordant diagnoses between cytology and histology in 19 of the 227 (∼8.4%) cases. CONCLUSIONS: EBUS-FNA cytology is a more efficacious diagnostic modality compared to EBUS-MFB.

Adult wilms' tumor metastatic to the lung: endobronchial ultrasound-guided fine needle aspiration biopsy.

Adult Wilms' tumor (WT) is a rare entity with less than 300 cases reported to date in the medical literature. Histologic and cytologic features of adult WT of the kidney are similar to findings in pediatric WT. While the lungs are noted to be the most frequent site of metastatic disease in the pediatric population, the incidence of lung metastases remains unknown for adult WT. A search revealed 38 cases of adult WT with lung metastases published to date in the English literature. Amongst these cases only two have utilized cytology of the lung lesions as a means to arrive at a final diagnosis. We report a case of adult WT metastatic to the lung that was initially diagnosed using endobronchial ultrasound-guided fine needle aspiration biopsy. The aim is to compare the current cytologic and immunohistochemical findings with those cases previously published, to outline the cytologic features of adult WT metastatic to the lung, and to emphasize the significance of cytologic diagnosis in the work-up of adult WT.

Predictive value of intra-abdominal lymph nodes in pancreatic endoscopic ultrasonography-guided fine-needle aspiration biopsy.

INTRODUCTION: Endoscopic ultrasonography (EUS)-guided fine-needle aspiration (FNA) biopsy is a commonly used method for the evaluation of pancreatic lesions. EUS-guided FNA of the intra-abdominal lymph nodes (LNs) can provide critical diagnostic information that is important for clinical management and tumor staging. This study examines the predictive value of intra-abdominal LN EUS-guided FNA biopsy associated with pancreatic lesions. MATERIALS AND METHODS: Over a 10-year period, the pathology database was searched for patients with concurrent pancreas and intra-abdominal LN EUS-guided FNA biopsy. The corresponding reports were reviewed, and clinical information and diagnostic results were recorded. RESULTS: There were 252 cases where both a pancreas lesion and intra-abdominal LN were biopsied. Of this group, 182 LNs were classified as negative (72%), 47 as positive (19%), and 23 as atypical (9%). Within the negative LN cohort, the pancreas FNAs fell into the following diagnostic categories: benign (47%), malignant (30%), and atypical/suspicious (23%). Within the positive LN cohort, the pancreas lesion correlated with the following diagnostic categories: malignant (89%), atypical (4%), and suspicious (6%). A positive LN EUS-guided FNA biopsy had a 98% positive predictive value for malignancy. Within the atypical LN cohort, the pancreas correlated with the following diagnostic categories: malignant (57%), atypical/suspicious (26%), and benign (17%). CONCLUSIONS: An atypical LN diagnostic category is strongly associated with a malignant pancreas lesion. A positive LN EUS-guided FNA biopsy has a 98% positive predictive value for pancreatic malignancy. A positive diagnostic category for an intra-abdominal LN can provide strong predictive evidence of a corresponding malignancy of the pancreas.

Telecytology for EBUS-FNA immediate adequacy assessment: implementation experience at a large academic medical center.

INTRODUCTION: Performing immediate assessment (IA) has become the standard of care for endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA) specimens. Despite the benefits of aiding interventional pulmonologists to achieve higher adequacy rates and fewer unnecessary passes, the time required by attending cytopathologists to be present for on-site assessments is significant and affects other clinical responsibilities. Telepathology, as implemented here, consists of a cytotechnologist-driven or trainee-driven microscope attached to a Nikon DS-Fi1 Camera and DS-L2 controller that displays dynamic microscopic images in real time on the attending pathologist's office computer. MATERIALS AND METHODS: Preliminary assessment results, final diagnoses, and corresponding surgical pathology diagnoses, when available, were compared between consecutive EBUS-FNA specimens acquired before and after implementation of telepathology-assisted IA. Cases were divided into 3 categories: satisfactory for evaluation, indeterminate for evaluation, and unsatisfactory for evaluation. RESULTS: During the first half of 2012, immediate assessments for adequacy were performed in person by attending pathologists for all cases in the EBUS-FNA suite. There were 209 adequacy assessments performed without the use of telepathology and 289 with telepathology. There were no differences in the relative distribution of satisfactory, indeterminate, and unsatisfactory for evaluation cases, the percentages of diagnostic samples relative to the adequacy category or in the histologic concordance between pretelepathology and post-telepathology cases. CONCLUSIONS: Telepathology-assisted IA of EBUS-FNA allowed for the same diagnostic accuracy as traditional on-site IA and is saves time for pathologists.

Utilization of p40 (ΔNp63) with p63 and cytokeratin 5/6 immunohistochemistry in non-small cell lung carcinoma fine-needle aspiration biopsy.

OBJECTIVE: Specific subclassification of pulmonary non-small cell carcinoma (NSCCA) is clinically necessary, and the aim of this study is to examine the utilization of p40 (ΔNp63) in fine-needle aspiration (FNA) biopsy for lung NSCCA. STUDY DESIGN: Database files of the Washington University Medical Center were searched. Patients who underwent endobronchial ultrasound and CT FNA of a primary lung neoplasia were selected and immunohistochemistry (IHC) was performed. A panel of markers was utilized, including p40, p63, cytokeratin (CK) 5/6, thyroid transcription factor, and napsin. RESULTS: One hundred patients were identified and comprised 38 squamous cell carcinomas (SCCA), 46 adenocarcinomas (AdCA), and 16 NSCCA. For SCCA, p40 was positive in 34/38 cases (89%) and negative in 4/38 cases (11%); p63 was positive in 33/38 cases (87%) and negative in 5/38 cases (13%); CK5/6 was positive in 38/38 cases. For AdCA cases, p40 was negative, p63 was positive in 2 cases (5%) and CK5/6 was negative in 43/46 cases (92%). CONCLUSION: For NSCCA, p40 had 89% sensitivity and 100% specificity compared to p63 with 86% sensitivity and 96% specificity and CK5/6 with 100% sensitivity and 96% specificity. In the evaluation of FNA biopsy for pulmonary NSCCA, p40 is a useful IHC marker for neoplastic subclassification, with better specificity in comparison to p63.

Rapid on-site evaluation for endoscopic ultrasound-guided fine-needle biopsy of the pancreas decreases the incidence of repeat biopsy procedures.

BACKGROUND: Rapid on-site evaluation (ROSE) for endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsy of the pancreas provides immediate feedback regarding cellular adequacy to aid in obtaining a definitive diagnosis and has the potential to avoid repeat procedures. The objective of the current study was to measure the impact of ROSE service on the incidence of repeat EUS FNA biopsy procedures. METHODS: Over a consecutive 3-year period, the pathology database at Washington University Medical Center was searched for patients with both an initial and subsequent EUS FNA biopsy demonstrating a solid lesion of the pancreas. These were divided temporally between the time before and after the introduction of ROSE service. Reports were reviewed and results were recorded. RESULTS: A total of 379 patients underwent ROSE service and 377 patients did not. The percentage of repeat non-ROSE EUS FNA cases was 5.8% and the percentage of repeat ROSE EUS FNA cases was 2.9%. The use of the ROSE service was found to decrease the number of repeat procedures by approximately 50% (P = .024). For those patients who underwent a repeat EUS-FNA procedure, the ROSE service provided a higher rate of definitive diagnosis among patients undergoing repeat procedures (67%) versus the non-ROSE cohort (27%). CONCLUSIONS: The use of ROSE for EUS-FNA biopsy of the pancreas was found to result in fewer patients undergoing repeat procedures. Patients who required a repeat procedure with the use of ROSE had a higher percentage of definitive diagnostic categorization on the repeat biopsy. Initial use of ROSE for EUS-FNA of solid pancreatic lesions was found to decrease the number of patients who required a repeat procedure.

Improved laboratory resource utilization and patient care with the use of rapid on-site evaluation for endobronchial ultrasound fine-needle aspiration biopsy.

BACKGROUND: Endobronchial ultrasound guided (EBUS) fine-needle aspiration (FNA) biopsy has become widely used to evaluate patients with thoracic abnormalities. Rapid on-site evaluation (ROSE) can provide the bronchoscopist with immediate evaluation findings during the procedure. This study examines EBUS FNA biopsy procedures with and without ROSE, and investigates the impact of ROSE service on the EBUS procedure and laboratory resource utilization. METHODS: The cytopathology database at Washington University Medical Center, St. Louis, Missouri, was searched for EBUS FNA biopsy cases before and after introduction of ROSE service, and a matched cohort was collected. Reports were reviewed and pertinent data was collected, such as sites biopsied, ROSE performance, slide smears, cell blocks, and diagnostic categories. Statistical analysis of the results was performed. RESULTS: A matched case-controlled EBUS FNA cohort of 340 patients (680 total) for each category of non-ROSE and ROSE service were identified. There was a 33% reduction in the number of sites biopsied with ROSE. A total of 68% of patients with ROSE had just one biopsy site compared to only 36% of non-ROSE patients. There was a 30% decrease in total slides (mean, 5.27 slides) after the introduction of ROSE. All of these improvements were statistically significant. CONCLUSIONS: EBUS FNA biopsy ROSE service benefits patients by contributing to significantly fewer biopsies and improved utilization of health care resources. ROSE service results in substantially fewer total slides, which has a significant impact on the cytopathology laboratory work effort. The use of ROSE for EBUS FNA biopsy provides significant improvements in patient care and laboratory resource utilization.

Perianal squamous cell carcinoma in-situ: a report of two human papilloma virus-negative cases.

We are reporting two cases of perianal squamous cell carcinoma in-situ, negative for high-risk (HR) and low-risk (LR) human papilloma viruses. A brief review of anal and perianal squamous cell carcinoma and the role of HPV are presented.

Primary squamous cell carcinoma of lung in a 13-year-old boy: a case report.

We are reporting a very rare case of primary bronchogenic squamous cell carcinoma (SCC) with bone metastasis in a 13-year-old boy. A brief review of the English literature on this rare neoplasm in childhood is presented.

Possible implantation carcinoma of the scalp following craniotomy for metastatic renal cell carcinoma.

We report a case of a 50-year-old man who developed a possible implantation carcinoma of the scalp within the craniotomy scar 19 months after a metastatic renal cell tumor nodule was removed from the brain. The English literature on the implantation carcinoma is briefly reviewed.