The fine needle aspiration appearances of Kikuchi's lymphadenitis.

OBJECTIVE: To describe the fine needle aspiration cytological appearances of Kikuchi's lymphadenitis. METHODS: Cytological review with histological correlation of all cases of Kikuchi's disease (KD) in which there had been an antecedent fine needle aspirate of the involved lymph node prior to lymph node excision between 2001 and 2006. RESULTS: Twelve cases of KD were identified in which cytological and histological material was available. In eight cases the original prospective diagnosis of necrotizing non-granulomatous lymphadenitis consistent with KD had been suggested on the lymph node aspirate. Review of these cytological samples identified abundant extra- and intracellular apoptotic debris - the latter embedded in the cytoplasm of crescentic and phagocytic macrophages, set in a background reactive lymphoid population. Three of 12 cases were initially reported as in keeping with nonspecific reactive lymphadenopathy. Review identified intracellular apoptotic debris but no conspicuous extracellular nuclear debris. One case had originally been reported as possible non-Hodgkin's lymphoma. Histological review of the excised lymph nodes in all 12 cases showed the classical appearances of KD. CONCLUSION: The accurate diagnosis of KD on fine needle aspiration is possible given correct clinical data, an adequately sampled and well-prepared specimen in which the characteristic intra- and extracellular apoptotic nuclear debris with admixed crescentic macrophages are identified on a reactive lymphoid background.

The use of cytospin monolayer technique in the cytological diagnosis of vulval and anal disease.

This pilot study investigated the use of the non-invasive cytospin monolayer technique in the diagnosis and screening of neoplastic and non-neoplastic vulval disease. Twenty-three patients (age range 34-86 years) attending a vulval disease clinic had brush cytology performed. The samples were prepared with a cytospin monolayer technique and the slides Papanicolaou-stained. Subsequent cytological interpretation and diagnosis were performed without knowledge of the clinical history and correlated with follow-up biopsy histopathology from each patient. Twenty-eight cytospin samples were analysed in total, of which 11 (39%) contained dyskaryotic cells which were assessed and a predicted VIN/AIN grade given. Ten of 11 samples (91%) reported as dyskaryotic had VIN/AIN on biopsy histology. One of 11 samples (9%) was reported as containing occasional squamous cells with borderline nuclear features and, although the corresponding biopsy did not show VIN, basal atypia was reported. One patient had features suggesting invasive carcinoma on cytology which was verified on subsequent biopsy. The 15 cases in which no dyskaryotic cells were identified did not show VIN or AIN on subsequent histology. Two cases were acellular and considered inadequate for cytological interpretation. The cytospin monolayer technique allows the diagnosis of neoplastic from non-neoplastic vulval disease. It is a quick, inexpensive and non-invasive method that may have a role in diagnosis, screening and surveillance of patients.

The use of the PAPNET automated cytological screening system for the diagnosis of oral squamous carcinoma.

The automated PAPNET screening system has been developed to recognize abnormal cells in cervical smears. Given that the oral mucosa sheds cells resembling superficial and intermediate cells of the cervix, the aim of this study was to assess whether the PAPNET system could be used to detect dysplastic cells in oral mucosal smears. Sixty-two oral smears from 27 patients were examined by both light microscopy and using the PAPNET system from clinically abnormal and normal areas by two pathologists. The clinically abnormal sites were also biopsied for histological analysis. There was 100% correlation between the manual and PAPNET screening results. Cytological interpretation of oral smears by both manual and PAPNET screening methods correctly diagnosed squamous cell carcinoma in 14/23 (61%) of patients who had all been confirmed by biopsy. The nine patients with false-negative cases could be attributed to poor smear technique and preparation. The PAPNET system can be used to identify abnormal cells in oral smears and, as such, may have an application for screening those populations at high risk of oral cancer--provided that adequate tuition is given in smear technique.

Biliary sludge: can ultrasound reliably detect the presence of crystals in bile?

OBJECTIVE: To determine the accuracy of routine gallbladder ultrasound in the detection of crystals in bile. METHODS: Preoperative ultrasonography was performed in 40 patients undergoing elective cholecystectomy. Bile was aspirated at operation and examined microscopically for the presence and quantity of crystals. RESULTS: Six patients had echogenic bile, five of whom had large numbers of crystals at microscopy, and one only a few crystals. Thirty-four patients had hypoechoic bile, nine had large numbers of crystals and 25 of these had few or no crystals at microscopy. For those patients with echogenic bile (hyper- or isoechoic) the sensitivity for detection of large numbers of crystals was 5/14 (35.7%) with a specificity of 25/26 (96%). However, if the bile was hypoechoic the sensitivity was 9/14 (65%). CONCLUSION: For those patients with echogenic bile, ultrasound is highly specific for the detection of crystals, although the sensitivity is low. By contrast, those patients with hypoechoic bile at ultrasound would need a further investigation to exclude the presence of crystals.

Diagnostic difficulty arising from rectal recovery in ulcerative colitis.

AIMS: To ascertain whether the dogma that a normal rectal biopsy precludes a diagnosis of ulcerative colitis is correct. METHODS: Rectal biopsy specimens from a prospective group of 24 asymptomatic patients, with an established diagnosis of ulcerative colitis, were examined in a blinded study alongside 10 normal rectal biopsy specimens from an age and sex matched patient cohort without ulcerative colitis. Each biopsy specimen was assessed by three pathologists and ascribed to one of four categories: normal; borderline abnormality (one or more minor nonspecific abnormalities which, when combined, did not fulfil the minimal acceptable criteria for a diagnosis of ulcerative colitis); minimal features of chronic ulcerative colitis; and unequivocal ulcerative colitis. RESULTS: Two patients with ulcerative colitis had normal biopsy specimens; nine specimens were categorised as borderline abnormality, one as showing the minimal changes of chronic ulcerative colitis, and 12 as having the typical changes of chronic ulcerative colitis. Thus, 11 (46%) of the 24 patients had a rectal biopsy specimen that was devoid of the acceptable attributes on which a diagnosis is established, despite a confident previous diagnosis. Ten of these 11 cases had disease limited to the rectum. Review of all previous histological biopsy specimens (n = 164) and clinical data, including drug treatment, failed to identify any attributes that might be prognostic markers for future rectal mucosal healing. CONCLUSIONS: A normal rectal biopsy specimen, though uncommon, may occur in longstanding colitis. Moreover, in 46% of these asymptomatic but established cases the degree of healing may preclude a diagnosis of ulcerative colitis without comprehensive clinical and radiological details. Pathologists need to be aware of this minimal end of the spectrum of disease.

Granulomas and hepatitis C.

Hepatitis C (HCV) is associated with a number of characteristic histological features. A recent paper has identified an increased frequency of granulomas in resection specimens from cases of HCV. We have carried out a retrospective study of 155 cases of HCV to assess the frequency of granulomas in biopsy specimens. We had two control groups: 151 cases of hepatitis B (HBV) and 129 cases of alcohol induced liver disease. Granulomas were found in 14 cases of HCV (10%), three cases of HBV (2%) and three cases of alcohol induced liver disease (2%). Granulomas were significantly commoner in cases of HCV than in the other two groups. Of the 14 cases of HCV, the granulomas could be ascribed to another cause in seven cases. When the analysis was carried out, excluding those granulomas which could be ascribed to another cause, they were still significantly commoner in cases of HCV. We conclude that granulomas are more frequent in HCV but that in half of cases in which they are found another cause can be identified. This means that if granulomas are seen in association with hepatitis C another aetiology should be sought before ascribing them to HCV.

Obstructive enterocolitis: a clinico-pathological discussion.

Obstructive colitis is a condition that is not widely appreciated by pathologists. It is defined as an ulcero-inflammatory lesion(s) proximal to a colonic obstruction from which it is separated by a variable length of normal mucosa. Five cases are described which illustrate the clinico-pathological spectrum of the condition. All presented surgically as acute intestinal obstruction, secondary to adenocarcinoma in four cases and a diverticular stricture in one case. Pathologically, the severity of colitis ranged from a single discrete ulcer to an extensive area of fulminant colitis indistinguishable from colitis indeterminate. Furthermore, two cases represented 'obstructive enteritis', a variant of obstructive disease not previously reported. Microscopically, all cases were characterized by distinctive areas of localized ulceration and active inflammation, the features of which were quite unlike those of Crohn's disease or ischaemia, separated by islands of normal mucosa. The role of mural hypoperfusion and secondary localized ischaemia in the pathogenesis of this disorder is discussed. It is suggested that colitis indeterminate represents the final common pathological pathway of the intestine to a wide range of initial insults, be they obstructive or inflammatory.

Cutaneous sarcoid-like granulomas in primary immunodeficiency disorders.

We report the occurrence of cutaneous sarcoid-like granulomas in one patient with common variable immunodeficiency and another with 'thymoma and hypogammaglobulinaemia'. To our knowledge, this is the first time that such skin lesions have been described in patients with primary immunodeficiency. These granulomas may be attributed to a combination of interleukin-2 deficiency and a profound CD4 lymphopenia. The lesions are similar to the non-infectious 'papular eruption' associated with human immunodeficiency virus infection, and might reflect a common pathogenic mechanism.

Helicobacter pylori: enough to give anyone an ulcer!

Since the early 1980s, research into gastritis and peptic ulcer disease has been dominated by Helicobacter pylori. This is a small, Gram-negative spiral bacterium which inhabits the mucus layer that coats the gastric mucosa. Colonisation of the human stomach by this bacterium is worldwide and, in certain continents, virtually ubiquitous. While histological gastritis is always the result, H. pylori-positive individuals are characteristically asymptomatic. Transmission is thought to be via the faecal-oral route and infection, usually acquired in childhood, will persist unless treatment supervenes. H. pylori is the main causative agent of peptic ulceration, but its role in non-ulcer dyspepsia is less clearcut. Recently epidemiological, histological and experimental data have been described linking H. pylori to gastric neoplasia--in particular adenocarcinoma and MALT lymphoma. A variety of treatment modalities exists for the eradication of this bacterium, and for adults the recommended drug therapy is a combination course of tetracycline, bismuth and metronidazole. Currently the new combination of omeprazole and amoxycillin is suggested as second-line treatment after failed triple therapy.