Impact on clinical follow-up of the Milan System for salivary gland cytology: A comparison with a traditional diagnostic classification.

INTRODUCTION: No universally accepted classification exists for salivary gland FNA. The proposed Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) offers a uniform classification with management recommendations. We compared FNA diagnoses from a prior study with specific diagnoses with corresponding MSRSGC diagnoses. METHODS: One-hundred and sixty-four cases from a prior cytological study with histological follow-up were re-reviewed by one of the authors and assigned to one of the MSRSGC categories. The original and MSRSCG diagnoses were compared, as were follow-up recommendations. RESULTS: The MSRSGC system classified 29 specimens as non-diagnostic (seven histologically shown to be benign salivary gland, two non-mucinous cysts, 14 sialadenitis, one pleomorphic adenoma, one haemangioma, one lymphoma, one adenoid cystic carcinoma, one squamous carcinoma and one benign lymphoid proliferation). The original study diagnosed these lesions as: seven benign cysts, 15 benign salivary gland tissue, one benign neoplasm and two insufficient for diagnosis. In seven cases, MSRSGC disagreed with original diagnoses and surgical resection showed lesions where optimal follow-up was more consistent with original cytological diagnosis. In 10 cases with disagreement, the MSRSGC was associated with a more appropriate follow-up based on the surgical diagnosis. Malignancy risks for the Milan categories were: non-diagnostic (12%), non-neoplastic (5%), atypia of undetermined significance (19%), neoplasm, benign (5%), neoplasm (40%), suspicious for malignancy (60%) and malignant (93%). CONCLUSION: MSRSGC was comparable with the original reported diagnoses in the majority of cases. Both systems had high accuracy for distinguishing benign from malignant lesions and both were associated with appropriate follow-up in most cases.

South African Menopause Society revised consensus position statement on menopausal hormone therapy, 2014.

The South African Menopause Society (SAMS) consensus position statement on menopausal hormone therapy (HT) 2014 is a revision of the SAMS Council consensus statement on menopausal HT published in the SAMJ in May 2007. Information presented in the previous statement has been re-evaluated and new evidence has been incorporated. While the recommendations pertaining to HT remain similar to those in the previous statement, the 2014 revision includes a wider range of clinical benefits for HT, the inclusion of non-hormonal alternatives such as selective serotonin reuptake inhibitors and serotonin noradrenaline reuptake inhibitors for the management of vasomotor symptoms, and an appraisal of bioidentical hormones and complementary medicines used for treatment of menopausal symptoms. New preparations that are likely to be more commonly used in the future are also mentioned. The revised statement emphasises that commencing HT during the 'therapeutic window of opportunity' maximises the benefit-to-risk profile of therapy in symptomatic menopausal women.

A retrospective clinical study of the treatment of high-grade anal dysplasia by infrared coagulation in a population of HIV-positive men who have sex with men.

HIV-positive men who have sex with men (MSM) are at high risk of developing human papillomavirus-associated anal squamous cell cancer. Similar to the management of cervical dysplasia, clinicians are treating high-grade anal dysplasia to prevent progression to cancer. Initial treatments such as cold scalpel excision and electrofulguration have shown limited efficacy in a HIV-positive population. Infrared coagulation (IRC) is an outpatient treatment for high-grade anal dysplasia. This retrospective clinical study reports on 68 HIV-positive MSM with 78 biopsy proven high-grade anal lesions. Each lesion was treated with the IRC with re-biopsy of the treatment site a mean of 140 days later. Of the 74 evaluable lesions; 39 had anal intraepithelial neoplasia (AIN) 1, 20 had AIN 2, seven had AIN 3, and eight had normal epithelium. The IRC showed 64% efficacy per treated lesion and shows promise as a treatment modality for high-grade anal dysplasia in this population.

The prevalence, and predictive value, of abnormal anal cytology to diagnose anal dysplasia in a population of HIV-positive men who have sex with men.

Due to the increasing incidence of anal cancer in HIV-positive men who have sex with men, and the potential to detect and treat high-grade anal dysplasia--the putative anal cancer precursor--we have introduced an anal cytology screening service. Patients with abnormal anal cytology have follow-up high-resolution anoscopy (HRA) with biopsy of lesions clinically suspicious for high-grade dysplasia. In total, 244 men were screened and 235 (96%) of the samples were adequate for cytological interpretation using the Bethesda 2001 system. One hundred and sixty-four (67%) men had abnormal anal cytology, and 93 of them had follow-up HRA and anal biopsy. The positive predictive value for any anal cytological abnormality to predict any degree of anal dysplasia was 95.7+/-2.1%, and for any anal cytological abnormality to predict high-grade anal dysplasia was 55.9+/-5.1%. Abnormal anal cytology was highly predicative of anal dysplasia on biopsy.

Cytokeratin 20 as an immunocytochemical marker for detection of urothelial carcinoma in atypical cytology: preliminary retrospective study on archived urine slides.

Previous studies have shown that expression of cytokeratin 20 (CK20), a constituent of intermediate filaments, is increased in malignant versus benign urine samples. To evaluate whether immunocytochemical staining of CK20 on archived urine slides could be used as a potential adjunct marker for triage of atypical urine cytology, we analyzed a total of 77 archived urine slides obtained from a spectrum of patients with various risks of developing urothelial carcinoma. These patients were divided into four groups on the basis of initial urine cytologic results and subsequent follow-up biopsy findings; group 1 had negative results in both evaluations, whereas the results in group 4 were positive for both cytology and biopsy. Groups 2 and 3 had a diagnosis of atypical urine cytology; however, patients in group 3 had a positive follow-up biopsy, and patients in group 2 did not. The Papanicolaou-stained archived urine slides were destained and then restained immunocytochemically with monoclonal antibody against CK20. With 5% positively stained nonumbrella cells as a threshold, CK20 was positive in 94.4% of group 3 or 4 patients. In contrast, CK20 was positive in 27.3% of group 2 patients and in 10.5% of group 1 patients. The overall sensitivity and specificity for CK20 for the detection of urothelial carcinoma in this population of patients were 94.4% and 80.5%, respectively. This study demonstrated that immunocytochemical analysis of CK20 on archived urine slides could be used to triage atypical urine cytology into low- and high-risk categories and that CK20 might be a simple and useful early detection marker for urothelial carcinoma.

Amyloid goiter in a case of systemic amyloidosis secondary to ankylosing spondylitis.

Infiltrative diseases of the thyroid include systemic sclerosis, hemochromatosis, sarcoidosis, chondrocalcinosis and amyloidosis. Only rarely does thyroid amyloidosis result in clinically palpable goiter. Classically, amyloidosis is associated with tuberculosis, rheumatoid arthritis, multiple myeloma or inflammatory bowel disease. Only rarely does clinical amyloidosis develop in the setting of ankylosing spondylitis. We describe a case of amyloid goiter in a patient with ankylosing spondylitis-associated amyloidosis.

Triple test approach to inadequate fine needle aspiration biopsies of palpable breast lesions.

OBJECTIVE: To perform a retrospective study evaluating the triple test for inadequate fine needle aspiration (FNA) biopsies of palpable breast lesions with a two-year clinical follow-up. STUDY DESIGN: All aspirates were reviewed and assessed for cellular adequacy in a one-year period. Specimen adequacy was based on the most stringent criteria, the presence of six or more epithelial cell clusters composed of at least six cells each. In all cases, clinical and radiologic results were reviewed and compared with the histologic outcome. RESULTS: Aspirates from 61 of 263 (23%) patients with palpable breast lesions that yielded nondiagnostic results were examined. The study showed a misdirected FNA rate of 21% and a misinterpreted rate of 1.6%. The other 77% of cases had benign surgical biopsies and/or clinical follow-up. Three of 61 (4.9%) cases with nondiagnostic smears were found to have cancer; two were inadequate due to misdirected aspirates, and one was misinterpreted microscopically. All cancer cases underwent surgical removal of the mass as a result of clinical or radiologic suspicion. CONCLUSION: We recommend utilizing the three diagnostic parameters of cytology, clinical findings and radiology, the "triple test," to achieve the best diagnostic accuracy in breast FNAs and to enhance patient management.

Recurrent secondary hyperparathyroidism after autotransplantation into the sternocleidomastoid muscle: report of a case with fine needle aspiration findings.

BACKGROUND: Recurrent hyperparathyroidism may occur following parathyroid autotransplantation due to autogenous function of the muscle-engrafted tissue. Parathyroid lesions are uncommonly diagnosed on cytology. CASE: A 31-year-old female with chronic renal failure presented with an elevated parathyroid hormone level and a neck mass in the left sternocleidomastoid muscle, the site of a previous parathyroid autograft. Fine needle aspiration of the mass revealed high cellularity, with perivascularly arranged, three-dimensional, branching clusters; individual cells; and naked nuclei exhibiting anisonucleosis. A diagnosis of parathyroid graft hyperplasia was made by fine needle aspiration and subsequently by histopathologic examination. CONCLUSION: Fine needle aspiration is an effective tool for confirming the presence of parathyroid autograft hyperplasia, thus allowing the correct surgical approach.

Fine needle aspiration biopsy of solitary fibrous tumor of the pleura. A report of two cases with a discussion of diagnostic pitfalls.

BACKGROUND: The diagnosis of a peripheral pulmonary nodule presents a challenge due to many diagnostic possibilities and pitfalls. We describe the cytologic features of solitary fibrous tumor of the pleura, differential diagnoses, pertinent immunohistochemical stains and histogenesis. CASES: Two cases of solitary fibrous tumor of the pleura showed two cell populations on cytologic preparations; mesothelial cells and spindle cells. The neoplastic spindle cell component was positive for CD-34 and vimentin but not for cytokeratin. CONCLUSION: Solitary fibrous tumor of the pleura is rare but should be included in the differential diagnosis of a peripheral pulmonary nodule. Fine needle aspiration biopsy is a safe and rapid method of providing a confirmatory diagnosis.

Fine needle aspiration diagnosis of fibromatosis colli. A report of three cases.

BACKGROUND: Fibromatosis colli, a common cause of congenital muscular torticollis, should be differentiated from other neck masses in infants. Invasive diagnostic and therapeutic measures should be avoided. CASES: Three infants under the age of 2 months presented with neck masses--a clinical suspicion of malignancy, lymphadenopathy and teratoma. The cytologic findings included dyshesive multinucleated skeletal muscle fragments showing degenerative and atrophic changes within a background of scattered reactive fibroblasts. CONCLUSION: Fine needle aspiration biopsy is a safe and rapid method of providing a confirmatory diagnosis of neck masses in infants.

What constitutes an adequate smear in fine-needle aspiration cytology of the breast?

BACKGROUND: The false-negative diagnosis is a major clinical concern and a significant cause of litigation in fine-needle aspiration cytology of breast lesions. A significant number of false-negative diagnoses may be due to inadequate sampling of these lesions. Little information is available in the literature about what constitutes an adequate specimen, and the few publications that address this issue propose criteria based on anecdotal information. Recommendations vary widely and may or may not take clinical findings into account. METHODS: The authors studied a subgroup of 183 cases with known outcome, drawn from a series of 1779 cases, to determine the minimum number of cell clusters necessary to ensure that adequate cellular material was present for accurate diagnosis. The series included 21 cases cytologically diagnosed as false-negative, 75 cases that had been correctly identified as benign, 47 cases cytologically designated as atypical, and 40 cases that on initial review had been correctly identified as malignant. In semiblind fashion, the smears from each case were assigned to low, medium, and high cellularity categories. Low cellularity was defined as 10 or fewer cell clusters, moderate cellularity was defined as 11-30 clusters, and high cellularity was defined as more than 30 clusters. A cell cluster was defined as five or more cells. Within the low cellularity group, exact numbers of cell clusters and the presence of individual cells were recorded. The presence of bipolar cells was used as an adjunct criterion for specimen adequacy, and the bipolar cells in each of 10 x 200 fields were counted. Cellularity was then correlated with diagnostic accuracy. RESULTS: Using a cutpoint of a cumulative score of 6 or more cell clusters or the prominence of bipolar cells (> or = 10 in each of 10 medium-power, x200 fields) for assessment of specimen adequacy, a false-negative rate of 1.5%, associated with an unsatisfactory rate of 20.2%, was obtained. CONCLUSIONS: Based on the data gathered in this study, the authors believe that the sampling false-negative and unsatisfactory rates can be minimized by selecting a cutpoint for satisfactory smears at a level of 6 or more cell clusters (cumulative total) or the presence > or = 10 intact bipolar cells per 10 medium-power fields (x200). Use of these criteria will decrease the false-negative rate of sampling in epithelial lesions of the breast. A false-negative rate of approximately 1.5% was obtained in association with an unsatisfactory rate of 20.2%. Using a cutpoint of 1 or more cell clusters, a false-negative rate of 2.1%, associated with an unsatisfactory rate of 13.7%, was obtained.

Mammographically guided fine-needle aspiration cytology of the breast: reducing the rate of insufficient specimens.

OBJECTIVE: The purpose of our study was to reduce the rate of insufficient specimens from fine-needle aspiration cytology (FNAC) of impalpable mammographically detected breast lesions. SUBJECTS AND METHODS: Our previous rate of insufficient specimens for FNAC was 27%. We implemented the following strategies to reduce this rate and improve accuracy: retraining of radiologists in FNAC procedures, more vigorous sampling, on-site evaluation of specimens by cytopathologist or cytotechnologist, exclusive use of stereotaxic guidance, stereotaxic equipment calibration program, and verification of initial needle placement. RESULTS: Of 77 patients with impalpable abnormalities who underwent FNAC with the new protocol, six (8%) had insufficient specimens for cytologic diagnosis: Four were incorrectly judged to contain sufficient material at the time of FNAC, one refused to complete the FNAC, and one had a vasovagal reaction. Of the six cases with insufficient specimens, four were benign at biopsy, one was malignant, and one was determined to be benign on the basis of mammographic stability. CONCLUSION: Modification of techniques and implementation of a quality assurance program can significantly improve the insufficient specimen rate for FNAC. Correlation of mammographic and cytologic findings also improves the management of these cases.

Initial clinical experience with dextran-coated superparamagnetic iron oxide for detection of lymph node metastases in patients with head and neck cancer.

PURPOSE: To investigate the efficacy of magnetic resonance (MR) imaging with dextran-coated superparamagnetic iron oxide in the differentiation of metastatic and benign nodes in patients with head and neck cancer. MATERIALS AND METHODS: MR imaging was performed before and after intravenous administration of iron oxide in 12 patients. Ninety-one pathologically proved nodes were visually analyzed, and 66 lymph nodes were quantitatively analyzed by measuring signal intensity in visually selected regions of interest. RESULTS: Forty of 42 histologically proved metastatic nodes and 41 of 49 benign nodes were detected, yielding 95% sensitivity and 84% specificity. The signal intensity ratio of benign nodes was substantially lower than that of metastatic nodes, indicating better differentiation of metastatic and benign nodes. Furthermore, 13 of 14 normal-sized nodes were detected. CONCLUSION: MR imaging with iron oxide can enable specific differentiation of metastatic and benign nodes in patients with head and neck cancer. This agent may potentially enhance the detection of metastatic lymph nodes and deserves further investigation.

The alcohol-fixed Diff-Quik stain. A novel rapid stain for the immediate interpretation of fine needle aspiration specimens.

A rapid alcohol-fixed Diff-Quik stain is described. The technique takes less than five minutes and results in excellent cytologic detail, comparable to that with Papanicolaou stain, as well as superb stromal definition. The stain should be very useful to pathologists and cytotechnologists for immediate interpretation of fine needle aspiration specimens.

Paranuclear blue inclusions in small cell undifferentiated carcinoma: a diagnostically useful finding demonstrated in fine-needle aspiration biopsy smears.

In a study of bone marrow aspiration smears, Wittchow et al. (Mod Pathol 1992;5:555-558) described a highly characteristic finding, paranuclear blue inclusions (PBIs), found almost exclusively in cases of metastatic small cell undifferentiated carcinoma (SCUC). PBIs are 1-4 microns, light blue, cytoplasmic inclusions best visualized with Romanowsky-type stains. These inclusions are most easily found indenting the nuclei within clusters of closely opposed tumor cells. In the current study air-dried fine-needle aspiration biopsy (FNAB) smears from 146 primary and metastatic small cell and non-small cell adult and childhood malignancies were reviewed. PBIs were found in 28/32 (88%) of SCUC but were observed in only 4/44 (9%) non-small cell carcinomas, 2/21 (9.5%) lymphomas, 1/8 (12.5%) melanomas, 0/14 sarcomas, and 6/27 (22%) small round cell neoplasms. These results suggest that the presence of PBIs in air-dried FNAB smears of adult neoplasms, while not pathognamonic of SCUC, are a diagnostically useful finding. PBIs may be seen in a variety of different childhood small round cell neoplasms which limits their utility in this setting. The recognition of PBIs is most important to the cytologist who may not have access to ancillary studies, such as immunohistochemistry and electron microscopy.

Pitfalls in the cytologic diagnosis of angiosarcoma of the breast by fine-needle aspiration: a case report.

This paper describes a case of angiosarcoma of the breast in a 26-yr-old female. The tumor, originally thought to be granulation tissue on fine-needle aspiration biopsy, was correctly identified as a malignant neoplasm of probable mesenchymal origin on a repeat FNA biopsy 4 mo later. A diagnosis of angiosarcoma was made on a subsequent excisional biopsy. Review of the cytologic features revealed findings that should suggest angiosarcoma, especially when correlated with the clinical history. The authors describe the cytological features seen in this case, and discuss an important pitfall in the diagnosis of angiosarcoma of the breast on FNA.

MRI and ultrasound guided interstitial Nd:YAG laser phototherapy for palliative treatment of advanced head and neck tumors: clinical experience.

Interstitial laser phototherapy (ILP) is a technique whereby laser energy is directly applied into tumors at variable depths. This technique is attractive, since it is minimally invasive and carries a low morbidity. It may allow treatment of deep and difficult to reach tumors in the head and neck and other areas when improved noninvasive monitoring techniques of laser-tissue interactions are developed. Recent studies demonstrate, respectively, the efficiency of ultrasound (UTZ) and magnetic resonance imaging (MRI) for real time interstitial needle placement in tumors, identification of vessels, monitoring and quantifying laser-induced tissue damages. We present a case in which a patient with recurrent, metastatic base of skull carcinoma has managed successfully with repeat ILP using MRI and UTZ guidance. Under heavy sedation, needles were placed in the tumor using MRI or UTZ guidance. Tumors were treated with a 600 mum flexible Nd:YAG laser fiberoptic passed through the needles. Laser-induced tissue photoablation was monitored using real time color flow Doppler UTZ or near real time fast spin-echo T2-weighted MRI. Posttreatment fine needle aspiration cytologic study demonstrated the presence of cellular debris and no viable cancer cells. Posttreatment follow-up MRI scans showed significant reduction of tumor size, and positron emission tomography (PET) revealed interval decrease in tumor metabolism. Treatments were accompanied by pain relief and improved functional abilities. ILP has now evolved into minimally invasive outpatient surgical procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

MR imaging-histopathologic correlation of thermal injuries induced with interstitial Nd:YAG laser irradiation in the chronic model.

Magnetic resonance (MR) imaging-histopathologic correlation of thermal injuries induced with interstitial laser irradiation was performed in a chronic model up to 12 weeks after laser exposure. T2-weighted MR images showed irreversible coagulative necrosis as a low-signal-intensity area. A higher-intensity surrounding area, corresponding to edema, was also present in acute lesions on T2-weighted images. Serial studies of the chronic model showed that a substantial portion of the interstitial edema zone progressed to coagulative necrosis up to 7 days after laser irradiation. This necrotic zone decreased in size beyond 2 weeks, presumably through biologic healing. MR imaging and pathologic findings correlated well in the chronic model. MR imaging has the potential to depict acute, irreversible thermal damage even before morphologic change is seen at the standard pathologic examination. Recognizing the dynamics of tissue response to interstitial laser irradiation on MR images is valuable for estimation of true lesion volume.

Malignant endometrial pathology.

This review discusses recent papers on endometrial carcinoma variants, immunohistochemical studies, and prognostic indicators. The aggressive nature of uterine papillary serous carcinoma is confirmed, even in the absence of myometrial or vascular invasion, with a comprehensive review of the histology, clinical presentation, and proposed treatment protocols. The possible etiologic role of radiation in the development of uterine papillary serous carcinoma is alluded to. The virulence of endometrial carcinomas with trophoblastic differentiation, endometrial carcinomas with a malignant giant cell component, and clear cell carcinomas of the endometrium is documented. A series of immunohistochemical studies is presented suggesting that uterine carcinosarcomas are metaplastic carcinomas derived from a common stem cell and that a shared histogenesis of endometrial stromal tumors and uterine mesoderm exists. Immunohistochemical techniques may clarify diagnostic problems of uterine tumors and their metastases and differentiate mucinous tumors of endometrium from endocervical origin. Staining of both carcinoembryonic antigen and ferritin in neoplastic endometria may be helpful in their differentiation from hyperplasias in curettage specimens. Significant prognosticators in endometrial carcinoma are depth of myometrial invasion and lymphovascular space involvement with greatest prognostic information provided by the depth of myometrial invasion above DNA index.

Hypercalcaemia in sarcoidosis co-existing with primary hyperparathyroidism. A case report.

Patients presenting with hypercalcaemia caused by the co-existence of sarcoidosis and primary hyperparathyroidism may present a diagnostic problem. Tests for sarcoid activity, together with the cortisone suppression test and an estimation of the immunoreactive parathyroid hormone level are all necessary to differentiate between those conditions.