Pulmonary sclerosing papillary adenoma.

Pulmonary papillary adenomas are very rare benign neoplasms, with approximately 24 cases reported in the English literature. They typically do not contain any more than an occasional focal area of sclerosis. Indeed, sclerotic interstitium within a sclerosing hemangioma has been reported to be a criterion used to distinguish it from pulmonary papillary adenoma. We present a case of pulmonary sclerosing papillary adenoma, with extensive sclerotic stroma and scattered areas containing typical papillary architecture.

False-negative Papanicolaou tests in women with biopsy-proven invasive endocervical adenocarcinoma/adenocarcinoma in situ: a retrospective analysis with assessment of interobserver agreement.

INTRODUCTION: The objectives of our study were to identify factors contributing to false-negative Papanicolaou (Pap) tests in patients with endocervical adenocarcinoma (EA) or adenocarcinoma in situ (AIS), and to analyze the impact of educational instruction on interobserver agreement in these cases. MATERIALS AND METHODS: False-negative Pap tests from patients with EA/AIS were reviewed by a consensus group and by 12 individual reviewers in 2 rounds, with an educational session on glandular neoplasia in Pap tests conducted between the 2 rounds. RESULTS: Of 79 Pap tests from patients with EA/AIS, 57 (72.2%) were diagnosed as abnormal and 22 (27.8%) as negative. Of the 22 false-negative cases, 10 remained negative on consensus review, with false-negative diagnoses attributed to sampling variance. The other 12 cases were upgraded to epithelial abnormalities (including 8 to glandular lesions). The false-negative diagnoses were attributed to screening variance in 2 cases and interpretive variance in 10 cases. On individual review, abnormal cells were misinterpreted as reactive glandular cells or endometrial cells in 7 of 8 and 5 of 8 cases upgraded to glandular abnormalities, respectively. With education, the proportion of individual reviewers demonstrating at least moderate agreement with the consensus diagnosis (Cohen's kappa >0.4) increased from 33% (4 of 12) to 75% (9 of 12). CONCLUSIONS: Sampling and interpretive variance each accounted for nearly one-half of the false-negative Pap tests, with underclassification as reactive glandular or endometrial cells the main source of the interpretive variances. Educational instruction significantly decreased the interpretive variance and interobserver variability in the diagnosis of glandular abnormalities.

Sclerosing mucoepidermoid carcinoma with eosinophilia of the thyroid: more aggressive than previously reported.

Sclerosing mucoepidermoid carcinoma with eosinophilia (SMECE) of the thyroid is a rare traditionally "low-grade" tumor that predominantly occurs in women. Approximately 50 cases have been reported in the literature. It arises in a background of Hashimoto thyroiditis and is characterized by nests of epidermoid and mucin-secreting cells located within an eosinophil-rich sclerotic stroma. Herein, we outline the clinicopathological and immunohistochemical characteristics of 6 cases of thyroid SMECE. All tumors were detected in women (age, 36-89 years; average, 59 years), and all patients underwent total thyroidectomies. Clinicopathological findings included extensive tumor invasion into the adjacent soft tissues, trachea, pharynx, and esophagus. Of 6 specimens, 5 had positive surgical margins. Cervical lymph node metastases were seen in 4, and distant metastases were in 3 patients. Immunohistochemically, all tumors were positive for CK19, galectin 3, and p63 and negative for calcitonin, calponin, S-100, and smooth muscle actin. Interestingly, 2 tumors also showed faint focal staining for thyroglobulin, and 2 others had focal positivity for thyroid transcription factor 1. Together, galectin 3 and CK19 expression supported the malignancy of these lesions, and p63 expression raised the possibility that these tumors originated from the ultimobranchial body. In summary, SMECE tumors in our series exhibit a clear female predominance with aggressive behavior and appear to arise from pluripotent solid cell nests. A correct diagnosis is crucial to providing SMECE patients with the appropriate treatment options, and we recommend a closer follow-up schedule than previously considered.

Five top stories in cytopathology.

CONTEXT: Cytology relies heavily on morphology to make diagnoses, and morphologic criteria have not changed much in recent years. The field is being shaped predominantly by new techniques for imaging and for acquiring and processing samples, advances in molecular diagnosis and therapeutics, and regulatory issues. OBJECTIVE: To review the importance of classical morphology in the future of cytopathology, to identify areas in which cytology is expanding or contracting in its scope, and to identify factors that are shaping the field. DATA SOURCES: Literature review. CONCLUSIONS: Five stories paint a picture in which classical cytomorphology will continue to have essential importance, both for diagnosis and for improving our understanding of cancer biology. New endoscopy and imaging techniques are replacing surgical biopsies with cytology samples. New molecularly targeted therapies offer a chance for cytology to play a major role, but they pose new challenges. New molecular tests have the potential to synergize with, but not replace, morphologic interpretation of thyroid fine-needle aspirations. Ultrasound-guided fine-needle aspiration performed by cytopathologists is opening a new field of "interventional cytopathology" with unique value. For the productive evolution of the field, it will be important for cytopathologists to play an active role in clinical trials that document the ability of cytology to achieve cost-effective health care outcomes.

Thyroid fine-needle aspiration reporting rates and outcomes before and after Bethesda implementation within a combined academic and community hospital system.

CONTEXT: The current study compares data from our hospital system before and after the 2008 implementation of the Bethesda System for Reporting Thyroid Cytology (BSRTC). OBJECTIVE: To show the effects the BSRTC has had on the reporting rates and outcomes for thyroid lesions. DESIGN: A search for thyroid fine-needle aspiration biopsies (FNABs) was performed for 2002-2005 (before BSRTC) and 2009-2011 (after BSRTC). Diagnostic outcomes were reviewed for cases with available follow-up. RESULTS: For 2002-2005, cytology reports for 3302 thyroid FNABs were reviewed, and 309 (9.4%) were classified as suspicious. For 2009-2011, cytology reports for 3432 thyroid FNABs were reviewed; 72 (2.1%) were classified as "atypia of undetermined significance or follicular lesion of undetermined significance" (AUS/FLUS), and 142 (4.1%) were classified as suspicious. Follow-up material was available for 31 AUS/FLUS cases (43.0%), and 6 of these cases (19%) were malignant. Follow-up material was available for 60 cases (42.3%) classified as suspicious, and 23 of these cases (38%) were malignant. CONCLUSIONS: The AUS/FLUS rate of 2.1% at our institution is at the lower range of the <7% recommended by the BSRTC, and our rate of 19% for risk of malignancy for AUS/FLUS is slightly above the BSRTC recommendation of 5% to 15%. Implementation of the BSRTC did not significantly affect our institution's reporting rates, most likely because an essentially similar classification system was employed before implementation of the BSRTC.

Embedding topic discovery in conditional random fields model for segmenting nuclei using multispectral data.

Segmentation of cells/nuclei is a challenging problem in 2-D histological and cytological images. Although a large number of algorithms have been proposed, newer efforts continue to be devoted to investigate robust models that could have high level of adaptability with regard to considerable amount of image variability. In this paper, we propose a multiclassification conditional random fields (CRFs) model using a combination of low-level cues (bottom-up) and high-level contextual information (top-down) for separating nuclei from the background. In our approach, the contextual information is extracted by an unsupervised topic discovery process, which efficiently helps to suppress segmentation errors caused by intensity inhomogeneity and variable chromatin texture. In addition, we propose a multilayer CRF, an extension of the traditional single-layer CRF, to handle high-dimensional dataset obtained through spectral microscopy, which provides combined benefits of spectroscopy and imaging microscopy, resulting in the ability to acquire spectral images of microscopic specimen. The approach is evaluated with color images, as well as spectral images. The overall accuracy of the proposed segmentation algorithm reaches 95% when applying multilayer CRF model to the spectral microscopy dataset. Experiments also show that our method outperforms seeded watershed, a widely used algorithm for cell segmentation.

Disseminated blastomycosis diagnosed by fine-needle aspiration of the thyroid.

Blastomycosis is an uncommon disease caused by the dimorphic fungus Blastomyces dermatitidis. It can manifest as chronic pulmonary symptoms or disseminated disease. Only three previous cases of blastomycosis involving the thyroid have been reported, of which two were diagnosed by fine-needle aspiration. We present a case of disseminated blastomycosis initially diagnosed by thyroid fine-needle aspiration. Our case was a 47-year-old man with past medical history significant for diabetes, hyperlipidemia, and chronic pancreatitis who presented with a 2-week history of fever, chills, rigors, constipation, and 10 pound weight loss. Abdominal CT revealed chronic pancreatitis and a calcified mass in the pancreas. Chest CT revealed a single 1.5-2 cm thyroid mass and innumerably small 2-3 mm pulmonary nodule bilaterally. Fine-needle aspiration of the thyroid demonstrated 10-20 µm broad-based budding yeasts with thick-walled, refractile capsules amidst a background of granulomatous inflammation, and was diagnosed as a fungal infection consistent with blastomycosis. The patient was started on treatment with itraconazole based upon the FNA diagnosis. Concurrent lung biopsy demonstrated rare possible yeast forms on histology. A specimen from the lung was sent for culture, and was positive for B. dermatitidis, confirming the diagnosis. Disseminated blastomycosis rarely involves the thyroid. However, the thyroid is amenable to fine-needle aspiration. Fungal and mycobacterial cultures and special stains for fungal organisms should be requested on all thyroid fine-needle aspiration biopsies with granulomatous inflammation.

Clinical outcomes for "suspicious" category in thyroid fine-needle aspiration biopsy: Patient's sex and nodule size are possible predictors of malignancy.

CONTEXT: Fine-needle aspiration (FNA) is recommended as an initial screening tool for the diagnosis of thyroid nodules. Approximately 10% of thyroid FNA diagnoses are "suspicious for neoplasm," warranting surgical resection. OBJECTIVES: To examine the role of a patient's age, sex, size of nodule, and morphologic features as possible predictors of malignancy in patients with cytologic diagnosis of "suspicious for neoplasm." DESIGN: Cytopathology slides and reports of 402 consecutive thyroid FNAs from 2000-2005 interpreted as "suspicious" were reviewed. Of these, 180 cases that had subsequent surgical resection were selected. RESULTS: Of the 108 cases suspicious for follicular neoplasm on cytologic evaluation, histologic follow-up showed malignancy in 26 (24%). Of the 37 cases suspicious for Hürthle cell neoplasm, 15 (41%) had malignancy. Of the 35 cases suspicious for malignancy, 29 had malignant histologic diagnoses. Among cases with cytologic diagnoses of "suspicious for follicular or Hürthle cell neoplasm," the rate of malignancy in female patients was 22% as compared to 43% in male patients (P = .02). The rate of malignancy in nodules less than 2 cm was 19% compared to 47% in nodules measuring 2 cm or larger (P < .001). These differences were statistically significant. No statistically significant difference was noted between the age of the patient and the rate of benign versus malignant diagnosis. CONCLUSIONS: Malignant tumors were more frequent in male patients with a cytologic diagnosis of "suspicious for follicular or Hürthle cell neoplasm" than in female patients. Risk of malignancy was higher in nodules measuring 2 cm or larger. Age of the patient was not a predictor of malignancy.