Malignant Perivascular Epitheloid Cell Tumor with an Unusual Immunophenotype in a Ten-Year-Old Child.

Introduction: Perivascular epitheloid cell tumors (PEComa) represent a group of usually benign mesenchymal neoplasms. Malignant variants are usually found only in adults.Case: We present a 10-year-old girl with infraclavicular malignant PEComa, negative for HMB-45 and Melan A but focally positive for MITF.Conclusion: To the best of our knowledge, no malignant variant of PEComa has been described in soft tissue in a child. Generally, PEComas are immunoreactive for HMB-45 and/or Melan A while our case was negative for both. Further studies are necessary to elucidate the significance of this immunohistochemical finding.

Concurrent Elevations of VEGF, Osteopontin and MCP-1 Serum Levels Are Independent Predictors of Survival in Patients with Diffuse Large B-Cell Lymphoma.

BACKGROUND: Diffuse large B-cell lymphomas (DLBCL) are heterogeneous diseases, and the identification of additional DLBCL risk factors is especially important. METHODS: In this pilot study, we determined pretreatment serum levels of vascular endothelial growth factor (VEGF), osteopontin (OPN) and macrophage chemotactic protein-1 (MCP-1) in 67 newly diagnosed DLBCL patients before treatment with standard chemoimmunotherapy and in 30 healthy persons. RESULTS: Serum levels of all three cytokines were significantly elevated in untreated patients compared to controls. VEGF and OPN concentrations were higher in patients with advanced Ann Arbor stage, B symptoms, Eastern Cooperative Oncology Group score ≥2, International Prognostic Index (IPI) ≥3 and partial/no remission. A high MCP-1 level was associated with advanced stage, increased IPI and bone marrow infiltration. In univariate analysis, elevated OPN and VEGF, and concurrent elevation of all three biomarkers, were identified as significant predictors of poor survival. Multivariate Cox analysis revealed that elevated OPN combined with elevated VEGF levels was one of the best parameter subsets predicting poorest survival. CONCLUSION: According to our preliminary results, serum levels of VEGF and OPN before treatment predict response to therapy and survival after chemoimmunotherapy, and may help to further stratify DLBCL patients into risk groups.

[Croatian Society for Clinical Cytology guidelines for thyroid cytology]. / Smjernice u citoloskoj dijagnostici stitnjace Hrvatskoga drustva za klinicku citologiju.

The main purpose of thyroid FNA (fine needle aspiration) is to separate malignant and possibly malignant nodules from benign thyroid lesions. Every patient with thyroid nodule is a candidate for FNA. Before a decision to perform an FNA, a complete history, a physical examination directed to the thyroid and cervical lymph nodes, a serum thyrotropin level, and thyroid ultrasound should be obtained. Thyroid lesion with a maximum diameter greater than 1.5 cm or nodule of any size with sonographically suspicious features is an indication for FNA. Ultrasound-guided FNA of the thyroid is recommended. The requisition form that accompanies FNA should contain the identifying data, location and size of the nodule, and relevant laboratory and clinical data. FNA diagnosis of thyroid disease is a clinicocytologic diagnosis, and correlation with clinical findings is mandatory for success. Thyroid FNA classification scheme consists of a four diagnostic categories according to the risk of malignancy: benign lesions, indeterminate lesions according to malignancy, malignant tumors, and non-diagnostic. Ancillary studies (immunocytochemistry, RT-PCR, flow cytometry) are usually helpful in borderline cases.

Additional cytomorphological criteria in diagnosis of pilomatricoma--benign tumor with bad reputation.

Pilomatricomas (PM) are benign skin appendageal tumors, with differentiation towards hair-forming cells, usually found in children. They are frequently misdiagnosed by clinicians, and there are also many reports of false positive diagnoses made on fine needle aspiration (FNA) cytology. PM are often mistaken for "small round blue cell" tumors in children, or for Merkel cell carcinoma, basalioma and metastatic small cell carcinoma in adults, with possible over-aggressive therapeutic approach. We present 6 cases of PM, correctly diagnosed preoperatively by FNA. Clinical, cytomorphologic and basic morphometric features were analyzed, and compared with 4 cases of malignant tumors with similar clinical presentation. Morphometric data (longest nuclear diameter) did not prove to be helpful, while basophilic cytoplasmatic protrusions, observed in all 6 analyzed cases, could be useful additional cytomorphologic feature of PM. We concluded that cytomorphologic characteristics of PM are reliable enough for correct preoperative diagnosis in adequate specimens, however the best results are achieved when FNA is performed by an experienced cytologist, and when all relevant clinical data are obtained.

Neonatal hemophagocytic lymphohistiocytosis--case report.

Hemophagocytic lymphohystiocytosis (HLH) represents a severe hyperinflammatory condition with the cardinal symptoms prolonged fever, hepatosplenomegaly, and cytopenias. The most prominent histopathological feature of HLH is an accumulation of activated T lymphocytes and macrophages predominantly in lymphoid tissues. Although it can occur in all age groups, neonatal-onset HLH is very rare. We report on a case of HLH presenting with anemia and respiratory distress at birth. Several weeks prior to diagnosis the symptoms were attributed to a systemic infection. The child developed typical clinical and laboratory findings, and was diagnosed with HLH according to HLH-2004 guidelines. Chemo-immunotherapy was initiated, but after a temporary control of the disease the patient succumbed to rapidly progressive HLH. Post-mortem, extensive hemophagocytosis was found in multiple organs. No specific genetic defect was identified. HLH is potentially fatal childhood disease. It is important for pediatricians to be able to early identify this disorder and commence the therapy before overwhelming disease activity develops.

[Single cell--definitive diagnosis! Where the profession ends and the art begins?]. / Jedna stanica--konacna dijagnoza! Gdje prestaje struka i pocinje umjetnost?

Cell is a morphologically and functionally the tiniest living organism, present from the very beginning of life on the Earth. Specialized cell types make up specific tissues and organs of the human body. Cell itself and cell elements are liable to morphological, functional, phenotypic and genotypic alterations in various physiological and pathological states. These alterations are studied by cytodiagnosis to diagnose the disease at cellular level. Cytologic examinations belong to the group of morphological, non-aggressive or minimally invasive tests that are easy to perform for both the patient and the professional. In addition, these tests are highly reliable and preferred to the related diagnostic procedures for providing immediate orientation and definitive diagnosis, thus saving both time and money. With the introduction of adjunctive technologies such as cell-surface marker analysis, computer image analysis, molecular and cytogenetic technologies performed on cytologic smears, cytology has become an ever more important factor in the diagnosis, subtyping and prognosis of malignant tumors. Thorough knowledge of cell morphology is a basis for proper performance and understanding of cytology techniques. A cytologist needs to be familiar with clinical manifestations of the disease and to be informed on all relevant data on the patient and his current and previous medical history, in order to be able to issue findings that are understandable and usable to all clinicians and patients. It requires close collaboration between the cytology laboratory and the ward, and among the cytologist, the patient and the clinician. Good collaboration with other diagnostic professions such as pathology, laboratory, molecular and cytogenetic diagnosis is by no means less important. Cytology as a profession implies knowledge of the morphological characteristics of normal cells and cells in various physiologic states, along with due knowledge of the morphology, phenotypic and genetic features of pathologic alterations. However, synchronizing and combining cytologic morphology with other sophisticated diagnostic procedures to reach an accurate diagnosis, subtyping and prognosis of tumor disease is artistry indeed.

Predictive Value of Intraoperative Sentinel Lymph Node Imprint Cytology Analysis for Metastasis in Patients with Melanoma.

Since there are no standardized protocols regarding the detection of microscopic melanoma deposits in sentinel lymph nodes (SLN), the aim of this study was to present our experience with intraoperative cytological evaluation of SLN in patients with melanoma. The study included 475 SLN biopsies (SLNB) from 201 patients with primary cutaneous melanoma of intermediate thickness. Each lymph node was cut in half; touch imprint cytology (TIC) preparations of all cut surfaces were performed and stained according to a modified May-Grünwald-Giemsa method. The results were compared to definitive postoperative histology. Twenty of 25 SLNB positive on TIC proved to be metastatic when compared to definitive histology. Most of 32 SLN that were suspicious but not diagnostic on TIC were proven negative (23/32, 71.8%), while 7 nodes had metastases (one micrometastasis and one with isolated tumor cells only). The majority (94%) of SLNBs negative on TIC remained negative on final histology, while 6% or 25 nodes were positive, mostly with micrometastases or isolated tumor cells (17/25). In frozen sections performed in cases of suspicious or positive SLN cytology, metastasis was confirmed in 80% of positive and in 21.9% of suspicious TIC. Altogether, 49% (27/55) of positive SLNB were identified intraoperatively in 57% (24/42) of patients, and in those cases a complete regional lymph node dissection was performed in the first step. TIC assessment of SLNB with 99% specificity and 57% sensitivity for intraoperative identification of metastasis is useful and beneficial for avoiding a second operative procedure.

Rapid Fatal Acute Peripheral T-Cell Lymphoma Associated With IgG Plasma Cell Leukemia and IgA Hypergammaglobulinemia.

Simultaneous occurrence of T-cell and B-cell neoplasms is rare, and etiologic relationships between these 2 malignancies are poorly understood. We describe the case of a 66-year-old woman who was admitted to the hospital because of fever, hemoptysis, lymphadenopathy, and skin rash. Enlarged lymph nodes in axillary, pectoral, paratracheal, and periportal regions as well as slight hepatomegaly and splenomegaly were confirmed. A peripheral blood smear revealed rouleaux formation and numerous circulating plasma cells, with plasmacytoid lymphocytes. Immunofixation-electrophoresis detected a monoclonal band defined as immunoglobulin (IgG)-lambda light chains with broad-band polyclonal IgA. The patient died from abrupt splenic rupture before diagnostic work-up was finished. Postmortem examination revealed infiltration of atypical lymphoid cells exhibiting high proliferative activity admixed with typical and atypical plasma cells in several organs. Thus, plasma cell leukemia (IgG-lambda) as a rare and aggressive variant of plasma cell myeloma in the present case was associated with aggressive peripheral T-cell lymphoma and polyclonal (IgA) plasmacytosis.

Plasma Levels of Monocyte Chemotactic Protein-1 Are Associated with Clinical Features and Angiogenesis in Patients with Multiple Myeloma.

The aim of this pilot study was to determine the plasma levels of monocyte chemotactic protein-1 (MCP-1) and possible associations with angiogenesis and the main clinical features of untreated patients with multiple myeloma (MM). ELISA was used to determine plasma MCP-1 levels in 45 newly diagnosed MM patients and 24 healthy controls. The blood vessels were highlighted by immunohistochemical staining, and computer-assisted image analysis was used for more objective and accurate determination of two parameters of angiogenesis: microvessel density (MVD) and total vascular area (TVA). The plasma levels of MCP-1 were compared to these parameters and the presence of anemia, renal dysfunction, and bone lesions. A significant positive correlation was found between plasma MCP-1 concentrations and TVA (p = 0.02). The MCP-1 levels were significantly higher in MM patients with evident bone lesions (p = 0.01), renal dysfunction (p = 0.02), or anemia (p = 0.04). Therefore, our preliminary results found a positive association between plasma MCP-1 levels, angiogenesis (expressed as TVA), and clinical features in patients with MM. However, additional prospective studies with a respectable number of patients should be performed to authenticate these results and establish MCP-1 as a possible target of active treatment.

Angioimmunoblastic lymphadenopathy with dysproteinemia following doxycycline administration.

Angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) is a primary lymphoproliferative T-cell disorder, currently classified as a peripheral T-cell non-Hodgkin's lymphoma. AILD is characterized by generalized lymphadenopathy, hepatosplenomegaly, immunological abnormalities, polyclonal hypergammaglobulinemia and anemia. We report a case of AILD in an 80-year-old male who presented with a generalized pruritic maculopapular eruption and fever following doxycycline administration. The maculopapular rash progressed to formation of confluent nodules, plaques and finally erythroderma with lymphadenopathy and hepatosplenomegaly. Blood analysis revealed an elevated erythrocyte sedimentation rate and polyclonal hypergammaglobulinemia. Lymph node biopsy showed almost complete effacement of the nodal architecture with diffuse proliferation of small vessels forming an arborizing network, surrounded by atypical lymphocytes, usually CD3+ CD4+ and occasionally CD3+ CD8+. There were also larger cells (immunoblastic shape) that displayed CD20 positively, some scattered plasma cells, and eosinophils. Histology of a cutaneous lesion showed spongiosis and infiltration of the epidermis by atypical lymphocytes with large hyperchromatic nuclei, perivascular dermal lymphocytic infiltrate (CD3+) mixed with plasma cells and occasional large immunoblasts (CD20+). During hospitalization the patient developed hemolytic anemia (Coombs positive) and lung metastases. The prognosis of AILD is generally poor, with a median survival of less than 20 months. Our patient died two and a half months after the diagnosis was made due to sepsis caused by Staphylococcus aureus isolated in hemoculture.

Metatarsal metastasis from transitional cell cancer of the urinary bladder.

Urinary bladder cancers can be grouped into three general categories: superficial, invasive and metastatic. Approximately 90% of malignant tumors of the urinary bladder are of epithelial origin and the majority of them are transitional cell carcinomas (TCC). Metastatic spread of urinary bladder cancers usually includes regional lymph nodes, the lung, the liver and the bones. The presence of metastasis tends to correlate with muscular wall invasion as often demonstrated at the initial diagnosis; consequently clinical bladder cancer represents a late phase of the disease. Although skeletal metastases of bladder cancers are rather common, they have been rarely described to occur in distal bones. For that reason, we report metatarsal metastasis from transitional cell cancer of the urinary bladder in a 59-year-old woman.

Plasma levels of osteopontin and vascular endothelial growth factor in association with clinical features and parameters of tumor burden in patients with multiple myeloma.

The aim of this pilot study was to determine the plasma levels of osteopontin (OPN) and vascular endothelial growth factor (VEGF) and find possible association between them and main clinical features and parameters of tumor burden in patient with multiple myeloma (MM). Plasma levels of OPN and VEGF were determined in 44 newly diagnosed MM patients and 24 healthy persons by ELISA method. These values were compared with the presence of anemia, renal dysfunction, and bone lesions as myeloma related clinical manifestations and with serum beta-2 microglobulin and Durie-Salmon clinical stage as prognosticators related to tumor mass. The value of OPN was significantly higher in MM patients with evident bone lesions (P = 0.03) and there was also a positive correlation with serum beta-2 microglobulin (r = 0.366; P = 0.04). Furthermore, patients with lower Durie-Salmon stage had significantly lower OPN and VEGF levels (P = 0.05; P = 0.04, resp.). Our preliminary results found positive association between plasma level of OPN, tumor burden, and bone destruction. Further analysis should provide information about the possible use of OPN as useful clinical biomarker for monitoring bone disease and tumor mass, as well as a prognostic factor, or a possible target for pharmacological intervention.

Myeloma cell morphology and morphometry in correlation with clinical stages and survival.

Multiple myeloma (MM) shows great variability in clinical course of the disease, and survival varies between a few months and more than 10 years. Myeloma plasma cells (PCs) can appear completely "normal" in morphology, but can also be overtly atypical, polymorphic, immature, as well as in all transitional forms. The aim of this investigation was to analyze the relationship between various morphological and morphometric parameters of myeloma cells, common staging/prognostic systems and survival in patients with MM. Sixty newly diagnosed MM patients were included in the study. Morphologic as well as basic morphometric features of myeloma PCs were analyzed in bone marrow (BM) aspirates, and compared with patient's clinical stage determined by Durie-Salmon and International Staging System, and with survival. We conclude that myeloma cell morphology has a prognostic potential. The most significant morphologic characteristics indicating shorter survival are: finding of >15% atypical PCs in BM aspirate, largest nuclear diameter/largest cytoplasmatic diameter of PCs ratio (maxND/maxCD)≥0.65, and anisocytosis expressed as standard deviation of maxCD ≥4.2 µm. Furthermore, PCs with irregular nuclei and absence of paranuclear clearing of the cytoplasm indicate more advanced stage of disease and worse prognosis. This preliminary results obtained on myeloma cells morphology and morphometry should be confirmed in the larger study which will include cytogenetic data as well as a therapeutic protocols applied.

Plasmacytoid urothelial carcinoma--diagnostic challenge in cytology.

Plasmacytoid urothelial carcinoma (PUC) is a very rare variant of urothelial carcinoma with an aggressive clinical course. According to small series reported to date, it is a high grade cancer usually diagnosed at an advanced stage, and with poor prognosis. Descriptions of the cytologic features of this type of carcinoma in literature are limited. Plasmacytoid appearance of tumor cells could cause diagnostic dilemma and potential incorrect diagnosis as multiple myeloma (MM). This report describes cerebrospinal fluid, bone marrow, and urine sediment cytomorphologic and immunocytochemical findings in a patient with meningeal carcinomatosis as the first manifestation of a PUC, initially misdiagnosed as MM with a brief review of the literature.

Assessment of bone marrow fibrosis and angiogenesis in monitoring patients with multiple myeloma.

The aim of our study was to emphasize the importance of accurate and standardized techniques for detailed monitoring of the microenvironment in multiple myeloma (MM). Bone marrow fibrosis, angiogenesis, and plasma cell infiltrates in bone marrow biopsy (BMB) samples at the time of diagnosis and on completion of therapy were analyzed for 42 patients with newly diagnosed MM. Computerized image analysis was used for all slides stained with anti-CD138 and anti-CD34. The patients with fibrosis in pretreatment BMB samples had significantly higher microvessel density (MVD) and plasma cell infiltrates. In posttreatment BMB samples, nonresponders had a significantly higher frequency and grade of fibrosis and higher values of MVD, total vascular area, and plasma cell percentage. The overall survival of nonresponders and patients with increased marrow fibrosis in posttreatment BMB samples was significantly shorter. The obtained results confirm that complex morphologic examination of the bone marrow microenvironment during the monitoring of MM can provide better prognostic significance.

Combined evaluation of bone marrow aspirate and biopsy is superior in the prognosis of multiple myeloma.

BACKGROUND: Estimation of plasma cell infiltrates in bone marrow aspirates (BMA) and bone marrow biopsy (BMB) is a standard method in the diagnosis and monitoring of multiple myeloma (MM). Plasma cell fraction in the bone marrow is therefore critical for the classification and optimal clinical management of patients with plasma cell dyscrasias. The aim of the study was to compare the percentage of plasma cells obtained by both methods with the patient clinical parameters and survival. METHODS: This retrospective study included BMA and BMB of 59 MM patients. The conventional differential count was determined in BMA to estimate the percentage and cytologic grade of plasma cells. The pattern of neoplastic infiltration and percentage of plasma cells were estimated on CD138 immunostained BMB slides microscopically and by computer-assisted image analysis (CIA). RESULTS: Significantly higher values of plasma cell infiltrates were observed in pathologist (47.7 +/- 24.8) and CIA (44.1 +/- 30.6) reports in comparison with cytologist analysis (30.6 +/- 17.1; P < 0.001 and P < 0.0048, respectively). BMB assessment by pathologist counting and using CIA showed strongest correlation (r = 0.8; P < 0.0001). Correlation was also observed between the pathologist and cytologist counts (r = 0.321; P = 0.015) as well as comparing the percentage of plasma cells in BMA and CIA (r = 0.27; P = 0.05). Patients with clinical stage I/II had a significantly lower CIA plasma cell count than those with clinical stage III (P = 0.008). Overall survival was shorter in patients with more than 25% of atypical plasma cell morphology estimated in BMA (P = 0.05) and a higher percentage of tumor cell infiltrates estimated by the pathologist and CIA (P = 0.0341 and P = 0.013, respectively). CONCLUSION: Study results suggested the combined analyses to be useful as a routine procedure to achieve more accurate and informative diagnostic data.