EUS-FNA of the Merkel cell carcinoma metastasis to the pancreas: Cytomorphology and immunocytochemistry on direct cytological smears.

OBJECTIVE: To report two cases of Merkel cell carcinoma (MCC) metastatic to the pancreas diagnosed with endoscopic ultrasound-guided-fine needle aspiration (EUS-FNA) and to add the case of concomitant chronic lymphocytic leukaemia/small lymphocytic lymphoma (CLL/SLL) and MCC to the literature. The aim is to alert the cytopathologists once more to the problems of differential diagnosis of pancreatic metastasis of MCC and to describe the possibilities of ancillary methods performed on direct cytological smears. METHODS: EUS-FNA procedures were performed according to standard institution protocol, using 22-G needles with cytopathologist on-site. Based on rapid on-site evaluation (ROSE), additional passes were made for immunocytochemistry (ICC). A mini panel of antibodies was used to aid the differential diagnosis. RESULTS: Smears revealed a dispersed pattern of small round cells with scant cytoplasm, round nuclei with inconspicuous nucleoli and occasional nuclear moulding, suspicious of small cell carcinoma. Results of ICC applied to the direct cytological smears were as follows: LCA negative, Cytokeratin (clone MNF116) positive, TTF-1 negative, CD 56 positive, NSE weakly positive, Chromogranin A weakly positive and CK20 positive, in one case in a dot-like perinuclear pattern. The diagnosis of MCC was made. CONCLUSION: Increasing incidence of MCC warrants the inclusion of MCC in the differential diagnosis of tumours of small round blue cell morphology even in unusual sites. The cytomorphological features coupled with an ICC panel are usually enough to make a confident diagnosis of MCC. EUS-FNA is a minimally invasive technique which enables sampling adequate tissue for all the ancillary methods eventually needed to support the diagnosis.

Role of repeated endoscopic ultrasound-guided fine needle aspiration in small solid pancreatic masses with previous indeterminate and negative cytological findings.

INTRODUCTION: Despite advances in imaging techniques, the differentiation between pancreatic cancer and benign lesions remains difficult. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an effective method for providing tissue diagnosis, but problems occur when lesions are small or the cytological diagnosis is indeterminate. AIM: To prospectively evaluate the utility of EUS-FNA in patients with small solid pancreatic lesions and those with initial indeterminate or negative cytological diagnosis. METHODS: During the study period we performed a total of 119 EUS-FNA procedures on 46 patients (mean age 56.3 years) for 47 small solid pancreatic lesions (range 7-30 mm, mean 17.2 mm in diameter). FNAs were performed in the presence of a cytopathologist. If cytological diagnoses were indeterminate, EUS-FNA was repeated within 3 weeks. Diagnoses were confirmed histologically or by follow-up (clinical and imaging: EUS +/- FNA and CT). RESULTS: Localization of the lesions: head 28 (60%), uncinate process 4 (9%), body 11 (23%) and tail 4 (9%). On average, 3.7 passes were performed. We observed no complications. Initial cytological findings were: malignant 17 (36%), benign 21 (45%), and indeterminate 9 (19%). 8 (78%) of the indeterminate findings were confirmed to be malignant on repeated procedures. A diagnosis of pancreatic cancer was subsequently confirmed in 1 patient who had a benign cytological finding. 19 patients underwent surgery. Histology confirmed a neoplasm in all cases. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were 68, 100, 100, 73 and 83%, respectively. After repeated EUS-FNAs of indeterminate findings sensitivity, negative predictive value and diagnostic accuracy rose to 92, 77 and 96%, respectively. CONCLUSION: EUS-FNA is a highly effective method for providing tissue diagnosis in patients with small solid pancreatic masses. Repeated procedures enhanced diagnostic accuracy in indeterminate findings, among which was high percentage of malignancies. EUS-FNA reduced the number of operations in patients with pancreatic solid masses.

Relation between urinary cytology abnormalities and cyclosporine A therapy in bone marrow transplant recipients.

The aim of the study was to determine the relationship, if any, between abnormalities in urinary cytology and the administration of cyclosporine A in bone marrow transplant recipients. Specific attention was given to the presence of tubular cells with round inclusions (TCRI). Two bone marrow transplant recipient groups were studied: one with allogeneic bone marrow transplantation (BMT) (20 patients) who were treated with cyclosporine A, and the other with autologous BMT (12 patients) who did not receive cyclosporine A. Urinary cytology showed TCRI in 41.66% of the patients after autologous BMT and in 80% of the patients after allogeneic BMT. In the group of patients treated with allogeneic BMT, the occurrence of TCRI was associated with a high incidence of glycosuria and was followed by an increase in the blood level of cyclosporine A, an increase in the serum creatinine concentration and a decrease in the creatinine clearance. These results demonstrated that TCRI, although related to, were not found to be exclusively specific to the administration of cyclosporine A.