Cytological changes induced by embolization in meningiomas.

OBJECTIVE: To describe cytological changes in meningiomas induced by embolization, which may be carried out a few days before surgery in order to soften the tumour and minimize intraoperative bleeding. Although histological changes have been described, we have found no description of such changes in the cytological literature. METHODS: We reviewed 22 cases of meningiomas with prior embolization in which cytological material was obtained during intraoperative consultation. In 13 of them recognizable cytological changes induced by embolization were present. On histology, these 13 tumours were grade I and showed intravascular embolic material. RESULTS: Cellular dissociation was prominent, with frequent single cells and small groups. Ischaemic cellular changes were a common finding and consisted of cell shrinkage, nuclear pyknosis and karyorrhexis. Confluent areas of necrosis were seen in one case. Additionally, numerous macrophages were present, many containing cellular debris, and neutrophils, giving a characteristic appearance of acute cellular ischaemia. Embolic material was seen cytologically in four cases as well-defined spherules surrounded by empty halos. Features of viable meningioma were recognized in all cases. CONCLUSION: Embolization of meningiomas induces cytological changes that mirror those seen on histology, but cellular dissociation with changes of ischaemia may result in a worrisome image. When faced with such changes the pathologist should consider the possibility of embolization, avoiding misdiagnosis of higher grade meningioma or metastatic carcinoma.

Fine needle aspiration cytology of basal cell adenoma of the salivary gland: a cytohistological correlation study of 35 cases.

OBJECTIVE: In order to evaluate the possibility of a specific cytological recognition of basal cell adenoma (BCA) we reviewed our experience with 35 histologically proven cases. Few series describing cytological features of BCA are available and diagnostic cytological criteria are not well established. METHODS: This study was based on 41 cytology samples from 35 patients with BCA. Thirty-five aspiration procedures were performed pre-operatively and six on tumour recurrence. Nineteen of the 35 patients were men and 16 women. The mean age at diagnosis was 55 years old (range 24-92). The series includes one non-representative case. Except for one tumour located in the upper lip, all of them involved the parotid gland. RESULTS: Aspirates were cellular, showing groups with dense, homogeneous metachromatic stroma and single cells. Relevant features were the trident-like configuration of groups, intimate relationship between neoplastic cells and stroma and cellular polymorphism. In approximately half of the cases a precise diagnosis was given. Most of the remaining tumours were diagnosed as benign but they were difficult to differentiate from pleomorphic adenoma. Regarding malignancy, there were two misdiagnoses of acinic cell carcinoma, due to high epithelial cellularity along with scarcity of stroma, and one case was considered to be suspicious of malignancy. CONCLUSION: BCA shows characteristic cytological features that allow a precise diagnosis. The main differential diagnosis is epithelial-rich pleomorphic adenoma, while acinic cell carcinoma is a potential false positive.

Interstitial disease associated with connective tissue disease and vasculitis.

Systemic autoimmune diseases comprise a complex, heterogeneous group of entities. Noteworthy among the pulmonary complications of these entities is interstitial involvement, which manifests with the same radiopathologic patterns as in idiopathic interstitial pneumonia. High-resolution computed tomography is the gold-standard imaging technique; it enables us to identify and classify the disease and to determine its extent, providing useful information about the prognosis. In this group of processes, the most common pattern of presentation is nonspecific interstitial pneumonia. It is essential for radiologists to work together in collaboration with other specialists to reach the correct diagnosis and enable appropriate, integrated treatment.

Role of fine needle aspiration cytology in the diagnosis and management of Warthin's tumour of the salivary glands.

OBJECTIVE: Local excision surgical procedures and non-surgical conservative management are considered alternatives to superficial parotidectomy in the treatment and management of Warthin's tumour (WT). Such therapeutic alternatives demand accurate diagnosis. In order to determine whether fine needle aspiration cytology (FNAC) is capable of rendering such a minimally invasive diagnosis, we evaluated its accuracy and diagnostic parameters in a large series of histologically proven cases of WT. METHODS: A cytohistological study of 116 salivary tumours from 110 patients (four WT were bilateral) with a histological or cytological diagnosis of WT. RESULTS: Histology confirmed the cytological diagnosis in 103 of 114 tumours (90.4%). Two tumours were incorrectly diagnosed on cytology as WT. In 11 cases of WT there was an erroneous or non-representative cytological diagnosis. The sensitivity was 90.4%, and positive predictive value 98.1%. Regarding malignancy, there were three misdiagnoses. One tumour diagnosed as WT was a low-grade mucoepidermoid carcinoma. Two cases considered 'suspicious of squamous cell carcinoma' corresponded to WT. After review, 81.3% of the cases of WT were considered typical and 18.7% non-typical; all misdiagnoses were in the latter group. Cytological difficulties could be divided into three areas: (i) absence of one or more diagnostic components; (ii) 'squamoid' pattern; and (iii) mucinous metaplasia. Degenerated oncocytes were present in 65% of cases. CONCLUSIONS: FNAC offers the possibility of a reliable diagnosis of WT. Pathologists must pay attention to the squamous appearance of degenerated oncocytes. Cytology, when coupled with clinical and image findings, may permit conservative tumour management.

Cytological features of chromophobe renal cell carcinoma, classic type. A report of nine cases.

OBJECTIVE: To review our experience with nine cases of chromophobe renal cell carcinoma (ChRCC), classic type. The cytological descriptions of this entity are still rare, and information concerning the diagnostic value of cytology is needed. METHODS: Nine cases of ChRCC evaluated using fine needle aspiration (n = 6) or intraoperative scrape cytology (n = 3) were selected. Expression of vimentin was evaluated in four cases using immunocytochemistry, which was performed on alcohol-fixed material. In all cases a complete pathological study was available. RESULTS: The neoplastic cells were arranged mainly as single cells and small, discohesive, monolayered groups. A polymorphous cellular population was identified, with coexisting large, small and intermediate-sized cells. The large neoplastic cells showed clear, flocculent cytoplasm with small, eccentric nuclei and frequent binucleation. Dense, homogeneous cytoplasm was most commonly seen in smaller cells. Clear cytoplasmic spaces resembling perinuclear halos were frequently observed, best appreciated in cells with more dense cytoplasm. Binucleation and a marginal nuclear location were commonly seen. Necrosis, basement membrane or other stromal material were absent. Vimentin was not expressed in the four cases analysed. Precise cytological recognition was possible in the last five cases. CONCLUSIONS: There is increasing evidence that a cytological diagnosis of ChRCC is possible. In our experience the histopathological features of ChRCC were well reflected in cytological samples, allowing specific recognition. In our cases the main differential diagnosis considered was clear cell carcinoma. Cytology can be especially helpful in the evaluation of intraoperative samples.

Epithelial-to-mesenchymal transition of mesothelial cells is an early event during peritoneal dialysis and is associated with high peritoneal transport.

Ultrafiltration (UF) failure is a consequence of long-term peritoneal dialysis (PD). Fibrosis, angiogenesis, and vasculopathy are causes of this functional disorder after 3-8 years on PD. Epithelial-to-mesenchymal transition (EMT) of mesothelial cell (MC) is a key process leading to peritoneal fibrosis with functional deterioration. Our purpose was to study the peritoneal anatomical changes during the first months on PD, and to correlate them with peritoneal functional parameters. We studied 35 stable PD patients for up to 2 years on PD, with a mean age of 45.3+/-14.5 years. Seventy-four percent of patients presented loss of the mesothelial layer, 46% fibrosis (>150 microm) and 17% in situ evidence of EMT (submesothelial cytokeratin staining), which increased over time. All patients with EMT showed myofibroblasts, while only 36% of patients without EMT had myofibroblasts. The number of peritoneal vessels did not vary when we compared different times on PD. Vasculopathy was present in 17% of the samples. Functional studies were used to define the peritoneal transport status. Patients in the highest quartile of mass transfer area coefficient of creatinine (Cr-MTAC) (>11.8 ml min(-1)) showed significantly higher EMT prevalence (P=0.016) but similar number of peritoneal vessels. In the multivariate analysis, the highest quartile of Cr-MTAC remained as an independent factor predicting the presence of EMT (odds ratio 12.4; confidence interval: 1.6-92; P=0.013) after adjusting for fibrosis (P=0.018). We concluded that, during the first 2 PD years, EMT of MCs is a frequent morphological change in the peritoneal membrane. High solute transport status is associated with its presence but not with increased number of peritoneal vessels.

[Usefulness of cytology in diagnosis and management of renal and perirenal tumors in adults]. / Utilidad de la citología en el diagnóstico y manejo de tumores renales y perirrenales del adulto.

INTRODUCTION: The use more and more extended of tumorectomy, partial nephrectomy and nonsurgical treatments of renal tumors has supposed a renewed interest in the diagnosis use of cytology. Whether during preoperative period, through the puncture aspiration with fine needle (PAAF), or during the intraoperative analysis, the cytology offers the possibility of a specific morphologic diagnosis. In this revision the information concerning the diagnostic value of the cytology in renal tumors is updated. MATERIAL AND METHODS: The references related to renal masses cytological descriptions has been reviewed. For this purpose we have searched both with computer in Medline data base and also manually. In the same way we include authors experience as much in the PAAF of these lesions as in the intraoperative use of the cytology. RESULTS: Between neoplasias with more cytological typical presentation are the clear cell renal and papillary carcinomas. The chromophobe and oncocytoma can show similarities, although the accumulated experience in the last years reflects that its differentiation is possible in most of the cases. For the diagnosis of angiomyolipoma, urothelial carcinoma and kidney metastasis, the clinical and image information are of great interest for the pathologist. The integration of these data usually allows a specific diagnosis. CONCLUSION: Generally, cytology reflects with accuracy the histological characteristics of renal neoplasias, allowing in many cases a specific diagnosis. We consider much appropriated the use of cytology, due to the more and more frequent situation of "incidentaloma". The PAAF minimum invasive nature and the possibility of performing a fast cytological analysis during intraoperative studies offer important information for the therapeutic management of these patients.

Tissue models of peritoneal fibrosis.

OBJECTIVE: To evaluate the utility of peritoneal pathologic samples, unrelated to peritoneal dialysis (PD) treatment, for the study of peritoneal fibrosis and inflammation. METHODS: Comparative morphologic and immunohistochemical study of peritoneal pathologic samples unrelated to PD with peritoneal biopsies from PD patients with special emphasis on the expression of myofibroblastic and epithelial-to-mesenchymal transition markers. RESULTS: Regarding morphology, PD-related simple fibrosis was less cellular, with greater stromal hyalinization, determining a homogeneous, hypocellular aspect of the submesothelium. In contrast, non-PD fibrosis was more cellular with an extracellular matrix showing a dense and fibrillar quality with wide bundles of collagen. Hylinazing vasculopathy was only present in PD samples. Myofibroblastic differentiation and epithelial-to-mesenchymal transition were common findings in all situations of peritoneal fibrosis. Calponin and calretinin are useful cellular markers to study such fibrogenic mechanisms and correlate with other well-known markers such as a -SMA and cytokeratins. Their expression was much more intense in those samples showing acute inflammation (peritonitis). CONCLUSIONS: Non-PD models of peritoneal fibrosis seem very useful to evaluate important features of human peritoneal pathology such us fibrogenesis, and inflammation. Fibrogenic events such as myofibroblastic differentiation and epithelial-to-mesenchymal transition are evident in these tissue samples allowing us to use them as an accessible source for in vivo and ex vivo studies. Both events show their maximal expression in situations of acute inflammation supporting the important role that peritonitis episodes play in the progression of fibrosis.

Myofibroblastic differentiation in simple peritoneal sclerosis.

OBJECTIVE: To analyze the presence of myofibroblasts in a series of peritoneal dialysis (PD) patients with simple sclerosis and non-PD, uremic patients. Since there is a close correlation between active fibrosis and myofibroblastic differentiation we wanted to test if myofibroblasts are present in uremic, non-PD peritoneal samples. To determine if there are correlations between myofibroblastic presence and other functional and morphologic peritoneal parameters. METHODS: Biopsies were collected from three patient groups: 1) Normal control samples (n = 15) of parietal and visceral peritoneum 2) non-PD uremic patients (n = 16); and 3) uremic patients on PD (n = 32). Peritoneal morphologic and functional parameters and immunohistochemical expression of alfa-smooth muscle actin was analyzed in each case. Vascular endothelial growth factor (VEGF), bcl-2 anti-apoptotic protein, and progesterone receptor was evaluated in a subset of cases. RESULTS: Myofibroblasts were present in 56.3% of the patients with PD-related simple sclerosis. In most cases they were distributed in the upper submesothelial area. None of the biopsies from normal controls and uremic, non-PD patients showed myofibroblasts. Within the group of PD patients, myofibroblasts showed no correlation with time on dialysis, urea/creatinine MTAC, episodes of peritonitis, submesothelial thickening, hyalinizing vasculopathy or mesothelial status. In a subset of PD patients VEGF expression was observed in submesothelial fibroblastic cells. No expression of progesterone receptor or bcl-2 was observed. CONCLUSIONS: Myofibroblasts are a reliable and simple indicator of fibrosis since they appear in early stages of PD treatment and in patients with minor morphologic anomalies. They are not exclusive of patients with sclerosing peritonitis, ultrafiltration loss or long standing treatment. Their absence in non-PD, uremic patients suggest that uremia-related fibrosis takes place without a significant participation of myofibroblasts.

Schinzel-Giedion syndrome: autopsy report and additional clinical manifestations.

Schinzel-Giedion syndrome (SGS) is a rare and incompletely defined condition. This is the third postmortem study on a boy with SGS and other unusual findings. He had a primitive neuroectodermal tumor in the lumbosacral region, bilateral syndactyly of hands and feet, and brain anomalies in addition to the major manifestations of the syndrome. We consider these clinical findings as possible additional manifestations of the syndrome since, of 19 SGS patients reported, 4 had syndactyly and 3 had embryonal tumors. In addition, the 3 published necropsy studies report brain anomalies. Knowledge that these changes occur in SGS may help facilitate diagnosis and improve our understanding of the syndrome.

Cystic transformation and calcium oxalate deposits in rete testis and efferent ducts in dialysis patients.

The histological study of the testes and epididymides obtained from autopsies of 24 men with chronic renal insufficiency revealed bilateral cystic transformation of the rete testis and efferent ducts in patients who underwent hemodialysis or peritoneal dialysis, but not in patients who did not receive this treatment. The lesion was associated with an accumulation of crystalline calcium oxalate deposits in the lumen of the rete testis and efferent ducts, and in the connective tissue adjacent to these excretory ducts. The rete testis epithelium showed columnar transformation with occasional papillary proliferations. Neither atypias or mitoses were observed. In three specimens, fibrosis and giant cell reactions was also present in the rete testis at the level of crystalline deposits. In three specimens, the caput epididymidis was enlarged, and the efferent ducts showed an increase in both tubular diameter and epithelial height, irregular outline, and development of diverticula. The lesions appeared within 30 months after the onset of dialysis.

Rete testis dysgenesis. A characteristic lesion of undescended testes.

OBJECTIVE: To evaluate the status of the intratesticular spermatic duct system (rete testis, RT) in patients with cryptorchidism. MATERIALS AND METHODS: We examined 40 surgical orchiectomy specimens from postpubertal patients with undescended testis from pathology files at La Paz Hospital, Madrid, Spain. Special attention was given to the intratesticular spermatic duct system, mainly the RT. RESULTS: In all cases, the RT was underdeveloped and was lined by columnar or large cuboidal cells (dysgenetic RT). According to the configuration of the mediastinal RT, the lesions were classified as diffuse hypoplastic RT (37.5%), hypoplastic-cystic RT (50%), or adenomatous pseudohyperplastic RT (12.5%). CONCLUSION: Although these changes could have resulted from incomplete pubertal maturation, many other data suggest that a primary abnormality of the RT is present. Important clinical considerations are derived from the fact that a functional obstruction of the sperm-conducting mechanism is determined by these abnormalities of the RT. The presence of intraluminal spermatozoa in epididymis and RT suggest that at least some of these patients are potentially fertile.

Fine-needle aspiration cytology of "proximal-type" epithelioid sarcoma.

The cytologic and immunocytologic findings in a case of recurrent "proximal-type" epithelioid sarcoma (ES) of the vulva are presented. This is a recently described neoplasm that differs clinically and morphologically from conventional ES. Cytologic smears showed a dissociated population of large, atypical neoplastic cells with bi- and multinucleated cells, abundant cytoplasm, and rhabdoid-like morphology. Due to its different clinical management it must be differentiated from metastatic carcinoma and melanoma. From a practical perspective, its differentiation from other epithelial-like sarcomas is less important. In conclusion the cytopathologic findings of "proximal-type" ES show a good correlation with histopathology, permitting the diagnosis of recurrences and metastases. When accompanied by adequate clinical information and ancillary studies, a specific preoperative recognition seems possible.

Fine-needle aspiration cytology of mesenchymal hamartoma of the liver.

The cytologic appearance of mesenchymal hepatic hamartoma in a 2-yr-old boy is described. Smears disclosed small groups and isolated, benign-appearing spindle cells admixed with scarce amounts of myxoid stroma and normal ductal cells and hepatocytes. Although the findings were nonspecific, cytology may rule out many other diagnostic possibilities and increases the preoperative capacity of clinical and image studies, leading to a more rational therapeutic decision.

Hodgkin's disease mimicking suppurative lymphadenitis: a fine-needle aspiration report of five cases.

Spontaneous, suppurative-necrotizing changes associated with Hodgkin's disease (HD) are not infrequent. They are mostly observed in the nodular sclerosis variant of HD and can cause an erroneous histologic diagnosis of suppurative lymphadenitis. Few cytologic reports describing this presentation of HD are available. We describe 5 cases of HD that showed cytologic abscess-like smears dominated by a massive neutrophilic infiltrate and necrosis. Since therapy can induce similar changes, this study did not include patients with known HD. In 2 cases erroneously diagnosed as suppurative lymphadenitis, the presence of neoplastic cells was minimal and only detected after revision. A third case was misdiagnosed as abscessified metastasic carcinoma. Two cases were correctly identified as HD, although in one, the possibility of anaplastic large-cell lymphoma could not be ruled out. In conclusion, necrosis and massive neutrophilic infiltrates can occur spontaneously and can be prominent findings in smears from patients with HD, mainly the nodular sclerosis variant. The cytopathologist should always consider this possibility in the presence of an abscessified, suppurative, lymphadenitis-like aspirate. A detailed search for the characteristic neoplastic cells of HD is mandatory in these cases.

Fine-needle aspiration cytology of mammary fibromatosis: report of two cases.

The purpose of this study is to evaluate cytologically two cases of mammary fibromatosis (MF). Prior to FNAC, clinical and mammographic suspicion of carcinoma and fibroadenoma were present. In both cases cytology disclosed the presence of numerous spindle cells admixed with epithelial cells. In the first case, carcinoma was excluded and the diagnosis of "spindle-cell proliferative lesion" was established. The second case was erroneously diagnosed as "cellular fibroadenoma" due to the presence of monolayered ductal epithelial groups and stromal tissue. In both cases local excision of the lesion was recommended. Although in a strict sense fibromatosis is a pure stromal lesion, the frequent presence of epithelial groups in the smears should raise a differential diagnosis with other more frequent mixed (epithelial and stromal) lesions such as fibroadenoma, cystosarcoma phyllodes, and metaplastic carcinoma. Due to the fact that clinically and mamographically MF is frequently confused with malignancy, preoperative recognition is essential since in many cases it would avoid unnecessary radical surgery. In this sense cytology offers very important preoperative information.

Fine-needle aspiration cytology of Kikuchi's lymphadenitis: a report of ten cases.

The purpose of this study was to evaluate the cytologic features of Kikuchi's lymphadenitis (KL). Smears from 10 patients with histologically proven KL were reviewed. In all cases, fine-needle aspiration (FNA) was performed prior to biopsy. To assess the validity of morphologic recognition, a blinded study, including smears from non-Hodgkin's lymphomas, nonspecific, and mycobacterial lymphadenitis was performed. At least 5 cases showed characteristic cytologic findings that permitted their specific recognition. A polymorphous lymphoid population with abundant karyorrhectic debris and histiocytes, many of which showed a small size and eccentrically placed, crescent nuclei, were characteristic features of KL. The remaining 5 cases failed to show typical findings and were indistinguishable from other nonspecific, reactive lymphadenopathies. When typical cytologic findings are present in an adequate clinical context (cervical nodes in young patients), a precise diagnosis is possible, avoiding unnecessary biopsies.