SHP2 is up-regulated in breast cancer cells and in infiltrating ductal carcinoma of the breast, implying its involvement in breast oncogenesis.

AIMS: To determine whether Src homology phosphotyrosyl phosphatase 2 (SHP2) is up-regulated in breast cancer and, if so, to determine whether its up-regulation has any relationship with clinical variables of breast cancer. METHODS AND RESULTS: Immunoblotting, immunohistochemistry and immunofluorescence microscopy were used to assess the state of SHP2 expression in breast cancer cells and in infiltrating ductal carcinoma (IDC) of breast. The possible role of SHP2 in breast cancer cell transformation was determined by dominant-negative expression and anchorage-independent growth assays. All of the breast cancer cell lines tested and 72% of IDC breast tumours analysed had increased amounts of the SHP2 protein. In support of its positive role, dominant-negative SHP2 blocked anchorage-independent growth of breast cancer cells. Furthermore, overexpression of SHP2 seemed to have a positive relationship to HER2 overexpression, nuclear accumulation of hormone receptors, higher tumour grade and lymph node metastasis, but not to age of breast cancer patients. CONCLUSION: SHP2 is a widely overexpressed signalling protein in IDC breast tumours. Given SHP2's positive role in cell growth, transformation and stem cell survival, the positive relationship of its overexpression to lymph node metastasis, nuclear accumulation of hormone receptors and higher tumour grade suggests that SHP2 promotes breast oncogenesis.

Malignant bone tumors associated with neurofibromatosis.

Neurofibromatosis (von Recklinghausen's disease), a phakomatosis inherited as an autosomal-dominant trait, predisposes to multiorgan neoplasia as well as to skeletal abnormalities. In an attempt to define more clearly the nature of osseous malignant lesions associated with von Recklinghausen's disease, we reviewed three cases of coexistent neurofibromatosis and malignant tumors of bone. None of the tumors was considered neurogenic. One patient had a fibrosarcoma, and two patients had malignant fibrous histiocytomas. No gross relationship to nerves was demonstrated, and special studies for axons were negative. Primary neurogenic sarcomas of bone are extremely rare; the diagnosis should be considered only when the tumor originates from an intraosseous nerve or contiguous neurofibroma. The occurrence of primary bone sarcomas in patients with neurofibromatosis seems to be a sporadic event.

Malignant histiocytosis: a clinical, histologic, and immunohistochemical study of 20 cases.

To better characterize the diagnostic criteria and clinical behavior of malignant histiocytosis, 20 patients treated at the Mayo Clinic during a 25-year period were studied. A wide spectrum of cytologic differentiation was observed, with cells ranging from bland to highly anaplastic; hemophagocytosis was prominent only in conjunction with a bland histologic appearance. In surgical specimens, the diagnosis of malignant histiocytosis necessitated the use of immunoperoxidase methods for lysozyme, immunoglobulin light chain, and alpha-antitrypsin content, as well as cytochemical stains for acid phosphatase and nonspecific esterase. All autopsies showed that organ involvement had varied somewhat from that reported earlier. The correct diagnosis of malignant histiocytosis was made prior to death in only ten of the 20 cases. The mean survival in the 17 fatal cases was 7.6 months; three of the seven patients treated by aggressive chemotherapy achieved complete remission. Relatively longer survival was correlated with initial confinement to the skin and the absence of cytopenia or liver function abnormalities. Three patients with pulmonary involvement from malignant histiocytosis had apparent inappropriate antidiuretic hormone secretion in the absence of central nervous system disease. The accelerated clinical progression of malignant histiocytosis and its response to current chemotherapeutic regimens make rapid diagnosis and familiarity with the pathologic variations seen in this disorder imperative. Routine utilization of special light-microscopic and immunohistochemical stains is mandatory.

Comparative features of ductal carcinoma in situ and infiltrating ductal carcinoma of the breast on fine-needle aspiration biopsy.

To evaluate the usefulness of fine-needle aspiration biopsy of the breast in separating ductal carcinoma in situ (DCIS) from infiltrating ductal carcinoma, the authors reviewed 16 preoperative fine-needle aspiration biopsies from biopsy-proven exclusive DCIS and 39 fine-needle aspiration biopsies from infiltrating ductal carcinomas with or without an in situ component. Seven (44%) of the DCIS and eight (21%) of the infiltrating ductal carcinomas had inadequate material for diagnosis on the aspiration biopsy. Five (32%) of the DCIS and 29 (74%) of the infiltrating ductal carcinomas caused suspicion or had positive results for malignancy. Four (25%) of the DCIS and two (5%) of the infiltrating ductal carcinomas showed atypical cells. Morphologic features of the atypical or malignant cells in the adequate specimens from these two lesions were similar except that the cells from the infiltrating ductal carcinomas showed more irregular nuclear spacing (94% vs. 44%, P less than 0.01) and more pronounced nuclear overlapping (65% vs. 33%) than those from the DCIS. In addition, the fine-needle aspiration biopsies of the DCIS tended to be hypocellular (less than 10 cells/10X) (44% vs. 6.5%, P less than 0.05) and to contain benign epithelial cells (22% vs. 6.5%) and macrophages (33% vs. 13%). Although the suspicion of DCIS might be raised when hypocellularity, benign epithelial cells, and macrophages are noted in a fine-needle aspiration biopsy of the breast that has positive results or causes suspicion for malignancy, fine-needle aspiration biopsy cannot be relied upon to distinguish DCIS from infiltrating ductal carcinoma.

Comparative features of carcinoma in situ and atypical ductal hyperplasia of the breast on fine-needle aspiration biopsy specimens.

With the use of fine-needle aspiration biopsy to evaluate non-palpable breast lesions, an increasing number of cases of ductal carcinoma in situ (DCIS) are encountered. The authors previously demonstrated that it is not possible to distinguish definitively between DCIS and invasive ductal carcinoma on fine-needle aspiration biopsy. To determine whether DCIS could be separated from atypical ductal hyperplasia (ADH), the authors identified all cases of exclusive DCIS or ADH with fine-needle aspiration biopsy before surgery. Sixteen cases of ADH and 19 cases of DCIS were identified. Of these, 12 in each category were sufficiently cellular to allow evaluation of architectural and cytologic features. Cases of ADH were more likely to be diagnosed as negative or atypical (11 of 12); in contrast, DCIS was more likely to be designated as suspicious or positive (9 of 12). Architectural and cytologic features characteristic of ADH included cells arranged in flat cohesive sheets, distinct cell borders, and myoepithelial cells. Those features characteristic of DCIS were single cells representing more than 10% of atypical cells, cellular dyshesion, and inflammatory background, coarsely granular chromatin, and nuclear pleomorphism. Many other features were not useful in separating ADH from DCIS. Based on this small series, it appears that the distinction between some cases of DCIS and ADH may be possible on fine-needle aspiration biopsy.

Fine-needle aspiration of Hürthle cell lesions. A cytomorphologic approach to diagnosis.

Hürthle cells may be found in fine-needle aspirates of the thyroid (FNATs) from Hürthle cell tumors (HCTs) and nonneoplastic Hürthle cell lesions, including Hashimoto's thyroiditis and goiter. To differentiate the characteristic cytomorphologic features from these lesions, the authors studied 38 surgically excised Hürthle cell lesions of the thyroid. Preoperative FNATs were reviewed for a number of architectural and cytologic features. The chi-squared and Fisher's exact tests were used for statistical analysis. There were many statistically significant cytologic differences between HCTs and nonneoplastic Hürthle cell lesions. Statistically significant features indicating an HCT versus nonneoplastic Hürthle cell lesion included the following: a high percentage (> 90%) of Hürthle cells, single Hürthle cells (> 10%), cellular dyshesion, large nucleoli, significant nuclear pleomorphism, significant nuclear enlargement, absence of macrophages, absence of plasma cells, and absence of or few lymphocytes. The architecture of cell groups, cellularity, amount of colloid, and multinucleation appeared to be of no value. The presence of a high percentage of dyshesive Hürthle cells with large nucleoli, with some cells showing significant nuclear enlargement and pleomorphism, associated with a lack of lymphoplasmacytic inflammatory cells, appears statistically predictive of an HCT and should enable the differentiation of an HCT from a nonneoplastic Hürthle cell lesion.

Asymptomatic first-trimester liver cell adenoma: diagnosis by fine-needle aspiration cytology with cytochemical and ultrastructural study.

A large asymptomatic first-trimester liver cell adenoma was diagnosed by fine-needle aspiration cytology. Therapeutic abortion was performed to reduce the rate of growth and achieve reduction in size before resection. Computed tomography scan evidence suggested that abrupt necrosis occurred after the therapeutic abortion, which might have precipitated an emergency partial hepatectomy. The tumor did not regress in size and was estrogen and progesterone receptor-assay negative.

Gastrointestinal cytology.

Since the development of the fiberoptic endoscope, laboratories have received cytologic specimens obtained from all segments of the gastrointestinal tract in increasing numbers to identify infectious agents and neoplasms. Adenocarcinomas generally are easily diagnosed and distinguished from reparative atypia, but their precursor lesions, dysplasia and adenomas, provide greater interpretive challenges. The same is true for such entities as malignant lymphomas. Most mesenchymal tumors remain outside the diagnostic capabilities of most cytologists.

Extradural spinal meningioma presenting as a neck mass. Diagnosis by aspiration cytology.

A case of a 36-year-old woman with an extradural spinal meningioma presenting as a neck mass is documented. Fine-needle aspiration biopsy was used as an initial diagnostic procedure and provided the diagnosis. Fine-needle aspiration biopsies are an excellent, cost-effective, diagnostic approach with low morbidity. Although these are underused, we recommend their use in the management of patients with neck masses. The entity of extradural spinal meningioma is briefly discussed.

Functioning parathyroid lipoadenoma. Report of a case diagnosed by intraoperative touch preparations.

Lipoadenoma of the parathyroid gland is an unusual cause of primary hyperparathyroidism. Inasmuch as they may grossly resemble lipoma more than parathyroid adenoma, these tumors may be missed by surgeons and surgical pathologists alike. In this case, the diagnosis was made during surgery utilizing touch preparations because frozen sections were technically difficult to perform due to the fat content of the tumor. Examination of multiple sections disclosed a neoplastic proliferation of parathyroid cells, thus supporting the premise that this entity represented an adenoma rather than a hamartoma.

Differential staining techniques in amniotic fluid cytology diagnosis of neural tube defects: a prospective study of 129 pregnancies.

In order to assess the utility of amniotic fluid cytology in the diagnosis of neural tube defects (NTDs), we performed a prospective study of 129 pregnancies selected for maternal age or history of prior congenital defects or multiple stillbirths. Amniotic fluid obtained between the 16th and 22nd weeks of gestation was cytocentrifuged and stained with hematoxylineosin (H&E), Papanicolaou, and Diff-Quik. Chromosomal analysis, amniotic fluid alpha fetoprotein (AFP) level, and eventual pregnancy outcome were recorded for each case. The AFP levels were normal in 128 cases, including two closed NTDs (meningomyelocele and encephalocele). Three patients had abnormal chromosomal studies: two with 47,XXX and one with trisomy 21. Of these 128 cases, 16 had inadequate cytologic preparations; the remainder, including the five aforementioned patients, showed predominantly squamous cells, amnion cells, and minicells. Other cell types, including genito-urinary cells, umbilical cord cells, respiratory cells, and macrophages, were also present in smaller numbers. One case exhibited a large population of small, darkly staining neural cells and large macrophages. The AFP in this case was markedly elevated, and the fetus was noted to be anencephalic. We found the H&E to be the preferred stain for both cytologic detail and minicell preservation; however papanicolaou was better for bloody specimens. Amniotic fluid cytology may provide a rapid and inexpensive method of confirming the diagnosis of open NTDs.

Comparative features of comedo and noncomedo ductal carcinoma in situ of the breast on fine-needle aspiration biopsy.

To determine whether fine-needle aspiration biopsy (FNAB) can differentiate between comedo (C-DCIS) and noncomedo ductal carcinoma in situ (NC-DCIS), we reviewed retrospectively the preoperative FNAB and surgical biopsy slides of 13 cases of DCIS with adequate cytologic material. Eight were NC-DCIS and 5 were C-DCIS. Three (60 percent) of the C-DCIS and 7 (88%) of the NC-DCIS were nonpalpable lesions biopsied under conventional mammographic guidance. Three (60%) of the C-DCIS but only 2 (25%) of the NC-DCIS were considered either suspicious or positive for malignancy on FNAB, the remainder in both groups being atypical. A statistically significant difference in marked nuclear pleomorphism (60% of C-DCIS vs. 0% of NC-DCIS, P = 0.04) and large nucleoli (60% of C-DCIS vs. 0% of NC-DCIS, P = 0.04) was observed between these 2 groups. DCIS is morphologically diverse, and it appears that the cytologic features of individual cells on FNAB may distinguish C-DCIS from NC-DCIS.

Tubal metaplasia: a cytologic study with comparison to other neoplastic and non-neoplastic conditions of the endocervix.

Tubal metaplasia of the endocervix (TME), a condition that may be confused morphologically with glandular neoplasia, is frequently found in cone or hysterectomy specimens. To determine the frequency of detecting TME in cytologic smears, we retrospectively reviewed 28 Papanicolaou (Pap) smears from 22 women (mean age 39.1 yr; range 25-60 yr) with histologically proven TME. Our criteria for TME were the presence of two cell types in addition to endocervical secretory cells, i.e., peg cells (cells with dark and granular cytoplasm and elongate nuclei) and ciliated cells. All women had cervical cytology specimens obtained with an endocervical brush shortly before the procedures in which TME was diagnosed, and five also had at least one post-procedure smear. Of 20 smears with an adequate, non-neoplastic endocervical component, TME was found in 2 (10%). In these two, TME cells constituted 10% and < 5% of all the glandular cells, respectively, and the percentage of ciliated cells in the TME was approximately 25% and 75%. In conclusion, TME was noted infrequently (10%) on the cervical cytosmears of women with histologically-proven TME. This result corresponds to the histologic finding that TME typically involves the upper endocervix and glandular epithelium, with only 13% of the women having TME on the surface of the lower endocervix. Atypical glandular cells on cervical cytology are a problem for clinicians and pathologists alike. The differential diagnosis of such atypia, including TME, cells of the lower uterine segment, squamous intraepithelial lesion in glands and glandular neoplasia, is discussed.

Fine needle aspiration of the breast. A probabilistic approach to diagnosis of carcinoma.

OBJECTIVE: To develop a classification scheme for reporting the results of fine needle aspiration (FNA) cytology of a breast lesion according to its likelihood of being a carcinoma. STUDY DESIGN: To verify the validity of this scheme, we studied a total of 267 FNAs that were prospectively classified according to predefined criteria as positive (76), suspicious (41), proliferative with atypia (66), proliferative without atypia (48) and unremarkable (36), and compared these results with the final histology. RESULTS: The percentages of patients who had carcinoma on histology were 100% (76), 93% (38), 35% (23), 6% (3) and 31% (11) of cases diagnosed as positive, suspicious, atypical proliferative, proliferative without atypia and unremarkable on cytology, respectively. However, if only invasive carcinoma is considered, then the percentage of carcinoma was 99% (75), 93% (38), 23% (15), 2% (1) and 11% (4), respectively. The only invasive carcinoma in the proliferative-without-atypia category was a tubular carcinoma and represented a false negative diagnosis. All four invasive carcinomas with an unremarkable cytologic diagnosis were due to sampling errors. Definitive surgery after FNA was common in cases with positive (65%) and suspicious (42%) cytologic diagnosis, whereas all but one patient with atypical, proliferative and unremarkable diagnoses had a biopsy initially. CONCLUSION: This scheme of reporting breast FNA results with defined criteria according to the probability of identifying carcinoma provides a rational basis for guidelines for the management of breast lesions.

Cytologic features of premalignant glandular lesions in the upper gastrointestinal tract.

The cytologic findings in 13 endoscopic brushing specimens from biopsy-proven premalignant glandular lesions (PGLs) of the upper gastrointestinal tract were reviewed retrospectively. The specimens were from ten patients: three with dysplasia in Barrett's esophagus, four with gastric adenomas and three with duodenal adenomas. One dysplasia in Barrett's esophagus and four adenomas (two gastric and two duodenal) had coexisting adenocarcinomas. Most pure PGLs were characterized cytologically by cohesive three-dimensional clusters of cells with more-or-less uniformly enlarged nuclei and an increased nuclear/cytoplasmic ratio. Crowding and molding were present within these clusters; however, the cells were arranged in a somewhat orderly or palisading fashion, instead of entirely haphazardly. In cases of carcinoma coexisting with adenoma or dysplasia, the atypical cells tended to be more pleomorphic and dyshesive. In one specimen from an adenocarcinoma arising in an adenoma, the adenomatous and carcinomatous components could be distinguished cytologically.

A triage system for processing fine needle aspiration cytology specimens.

Fine needle aspiration (FNA) cytology is increasingly used in the operating room, in radiology suites and in physicians' offices. A major cause of nondiagnostic FNA specimens is poor preparation techniques. To avoid this problem, we have developed a triage system for handling and preparing FNA specimens. (1) For aspirations performed without a cytotechnologist present, the aspirate is rinsed into 50% ethanol; Cytospin slides are then prepared and stained by the Papanicolaou method. Clinicians are disposed toward this indirect method since no special slide preparation techniques are necessary. The results are equal to those of direct smear preparations, and material so prepared may also be used for immunocytochemistry. (2) When a cytotechnologist is present, both direct and indirect preparations are made. (3) When an immediate interpretation is desired, to ensure adequacy and/or to make a diagnosis, alcohol-fixed direct smears are stained with a modified toluidine blue-eosin stain and read by the cytopathologist. This offers the advantage of a quick diagnosis, which may be made in less than 90 seconds, but with nuclear detail equal to that of the Papanicolaou stain and with good background staining. In summary, our three-tiered approach offers optimal processing for aspirates collected in various settings in our institution.

Brushing cytology of the upper gastrointestinal tract. Obsolete or not?

The merit of brushing cytology of the upper gastrointestinal tract has been questioned since it appears to duplicate biopsy. To determine its value, the reports on all endoscopic biopsy and cytology specimens from a one-year period were reviewed. The 683 procedures included 481 in which only a histologic biopsy sample was obtained, 47 in which only a cytologic brushing sample was obtained and 155 in which both types of samples were obtained ("combined specimens"). Among the 155 combined specimens, 4 of the confirmed malignancies were detected by histology only while 2 were detected by cytology only. A diagnosis of suspicious or positive for malignancy was made for 20% of the combined specimens as compared to less than 5% of the biopsy-only or brushing-only specimens. While 15% of the specimens that included a brushing sample (either alone or with biopsy) showed fungal infections, only 1.2% of the biopsy-only specimens did. It appears that the clinicians at this hospital tend to use brushing in combination with biopsy when either a malignancy or a fungal infection is suspected. Other empiric advantages of endoscopic brushing cytology include its rapid turn-around time, minimal invasiveness and good recognition of lymphoid cells. The selective use of brushing cytology should increase the probability of detecting malignancies and fungal infections without any increased risk or discomfort to the patients.

Comparison of different preparation techniques for fine needle aspiration specimens. A semiquantitative and statistical analysis.

Different options exist for preparing fine needle aspiration specimens (FNAS). To compare direct smears and cytocentrifugation specimens, we prospectively obtained FNAS from 38 operative cases, making alcohol-fixed (DIR) and air-dried (AIR) direct smears and collecting additional passes in 50% ethanol (ETH), Saccomanno's solution (SAC) and Hanks' Balanced Salt Solution (HBSS). All slides were stained with Papanicolaou stain except AIR, which were stained with Diff-Quik. We evaluated cellularity, nuclear and cytoplasmic preservation, percent single cells, background and degree of three-dimensionality on a 0-3+ scale and rendered an independent diagnosis for each medium. Statistical analysis of differences between techniques was performed utilizing the paired t test. Cellularity was significantly decreased for ETH, HBSS and SAC as compared to DIFF and DIR. Nuclear preservation was best for DIR and inferior for AIR, ETH, SAC and HBSS. Background was best seen in DIR and AIR as compared to ETH and SAC. HBSS was significantly inferior to DIR but not to AIR. There were no significant differences in cytoplasmic preservation and percent single cells. Three-dimensionality was increased for ETH and SAC but not for HBSS. The ability to make a definitive diagnosis was significantly inferior only for HBSS and SAC as compared to AIR. Direct smears made by cytotechnologists or pathologists are better than Cytospin specimens. However, despite their inherent disadvantages, rinse techniques may be advantageous when specimens are collected solely by clinicians.

Cytologic diagnosis of cytomegaloviral esophagitis. A report of three acquired immunodeficiency syndrome-related cases.

Cytomegalovirus (CMV) is recognized as a common cause of infectious esophagitis in patients with the acquired immunodeficiency syndrome (AIDS). The radiographic and endoscopic findings are variable, and although some features are suggestive of CMV esophagitis, none is specific. The mainstay of the diagnosis of this disease has been histologic demonstration of the characteristic intranuclear and intracytoplasmic inclusions. We report three patients with AIDS-related CMV esophagitis in whom cytologic smears from esophageal brushings contained diagnostic cells characterized by nuclear and cytoplasmic enlargement; marginated chromatin; large, basophilic intranuclear inclusions surrounded by a clear halo; and granular, eosinophilic intracytoplasmic inclusions. In one case the initial diagnosis was made from the biopsies, and only after careful review were cells diagnostic of CMV infection identified in the cytologic smears. In that patient, numerous cells with herpes simplex virus-related changes were present and probably masked the presence of the CMV-infected cells. In contrast, the biopsies from another patient showed only necrotic debris and inflammatory cells, whereas the cytologic preparations revealed cells with the characteristic CMV inclusions. With improved therapy for this often-debilitating opportunistic infection, rapid and accurate diagnosis is imperative. Cytology complements histology, and concurrent use of these diagnostic modalities will detect CMV esophagitis more frequently than will either technique alone.