Cytopathology of extracranial ectopic and metastatic meningiomas.

INTRODUCTION: Extracranial meningiomas may infrequently be encountered as ectopic or metastatic tumors. Their rarity and unique cytomorphology often pose significant diagnostic dilemmas. The aim of this study was to report our experience with a series of ectopic and metastatic meningiomas, characterizing their cytomorphology with histological correlation. MATERIALS AND METHODS: A retrospective analysis involving 13 patients with cytological preparations from extracranial meningiomas was performed. Cytology cases were correlated with available surgical resection specimens. Data regarding clinical findings, tumor information, cytomorphology, follow-up histological features and immunohistochemistry were recorded and analyzed. RESULTS: There were 5 cases with metastases and 8 ectopic meningiomas. Metastases occurred in the scalp/skull, lung, paraspinal soft tissue and liver. Primary ectopic meningiomas were located in the paranasal sinuses and ear, orbit and neck. Cytomorphological features characteristic of meningiomas were identified in the majority of samples including tightly cohesive clusters of spindled cells, whorls, intranuclear inclusions, nuclear grooves and psammomatous calcification. Unusual cytomorphological features identified in only a few cases included epithelioid cell predominance, abundant inflammatory cells, small-cell change, papillary structures and pseudoacinar growth. Metastatic tumors exhibited more nuclear atypia and occasionally mitoses or necrosis. Meningiomas were shown to be immunoreactive for epithelial membrane antigen, pancytokeratin and vimentin. CONCLUSION: Although rare, extracranial meningiomas can be encountered in cytologic specimens and should be included in the differential diagnosis when characteristic morphological features of meningiomas are seen. Cytopathologists should be aware that these lesions could be mistaken for other tumors, especially when confounded by atypia and unusual cytomorphological features.

Indeterminate pediatric thyroid fine needle aspirations: a study of 68 cases.

OBJECTIVE: The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) provides a reporting scheme for thyroid fine needle aspiration (FNA) and includes three indeterminate categories with different management strategies. This study analyzes indeterminate thyroid FNAs in children, and correlates these findings with the histological features. METHODS: A total of 179 thyroid FNA specimens were retrieved from children. Cases were categorized by TBSRTC. Only cases diagnosed as atypia (AUS)/follicular lesion of undetermined significance (FLUS), suspicious for follicular or oncocytic neoplasm (SFON), or suspicious for malignancy (SM) were selected and correlated with the nodule size and histological follow-up. RESULTS: Sixty-eight cases were identified, including 43 (63%) AUS/FLUS diagnoses, 19 (28%) SFON, and 6 (9%) SM. On follow-up, 48% were malignant, including 28% AUS/FLUS cases, 58% SFON, and 100% SM. The average size of the malignant lesions diagnosed preoperatively as AUS/FLUS was 1.5 cm (range 0.7-4.5), compared to 3.3 cm (range 1.2-6.6) in SFON and 2.8 cm (range 0.7-3.8) in SM. Malignancies included 92% papillary thyroid carcinoma (PTC), 77% of which were the follicular variant of PTC (FVPTC) and 8% follicular carcinomas. The AUS/FLUS cases were largely due to compromised specimens (49%) and the highest malignancy rate occurred in those with cytological atypia (50%). CONCLUSIONS: This study shows an incremental risk of malignancy within the indeterminate categories using TBSRTC in children. Malignant nodules with a preoperative AUS/FLUS diagnosis tended to be smaller than those with a SFON or SM diagnosis, and the vast majority of malignancies were PTC, with a high proportion being FVPTC.

Cytomorphology of unusual infectious entities in the Pap test.

Rare entities in the Pap test, including neoplastic and non-neoplastic conditions, pose challenges due to their infrequent occurrence in the daily practice of cytology. Furthermore, these conditions give rise to important diagnostic pitfalls. Infections such as tuberculosis cervicitis may be erroneously diagnosed as carcinoma, whereas others, such as schistosomiasis, are associated with squamous cell carcinoma. These cases include granuloma inguinale (donovanosis), tuberculosis, coccidioidomycosis, schistosomiasis, taeniasis, and molluscum contagiosum diagnosed in Pap tests. Granuloma inguinale shows histiocytes that contain intracytoplasmic bacteria (Donovan bodies). Tuberculosis is characterized by necrotizing granulomatous inflammation with Langhans-multinucleated giant cells. Coccidioidomycosis may show large intact or ruptured fungal spherules associated with endospores. Schistosoma haematobium is diagnosed by finding characteristic ova with a terminal spine. Molluscum contagiosum is characterized by the appearance of squamous cells with molluscum bodies. This article reviews the cytomorphology of selected rare infections and focuses on their cytomorphology, differential diagnosis, and role of ancillary diagnostic studies.

Vegetable cell contaminants in urinary bladder diversion cytology specimens.

OBJECTIVE: We identified unique vegetable cell-like structures in urinary diversion specimens. This study aimed to describe their cytomorphology and prevalence and to investigate the possible origin of these contaminants. STUDY DESIGN: A 10-year retrospective review of urinary diversion urine specimens with reported vegetable cell-like structures was performed. Data regarding patient demographics, previous history and specimen cytomorphology were recorded. To determine their prevalence, 100 urinary diversion cases were screened. Stoma materials were evaluated as possible contaminant sources. RESULTS: A total of 11 urine cases from 7 patients (mean age 64 years; male/female ratio 2.5:1; all with ileal conduits) were identified with contaminating vegetable cell-like structures. These thick-walled cells contained dense, smudged cores and pericentral clearing. In 27% of cases, the specimens were less than optimal or unsatisfactory for evaluation due to low cellularity and associated lubricant material. No contaminating vegetable cell-like structures were found in the 100 screened cases. Stoma care products tested did not yield any morphologically similar structures. CONCLUSION: Vegetable cell-like structures may rarely be identified as a contaminant in urinary diversion specimens, possibly from stoma care material. Associated lubricant may affect specimen adequacy. These vegetable cell-like structures must be distinguished from true pathologic structures such as koilocytes or parasitic ova.

Salivary duct carcinoma with striking neutrophil-tumor cell cannibalism.

Cannibalism of neutrophils by tumor cells has previously been reported in certain carcinomas, lymphoma and melanoma. Tumor cannibalism is believed to serve as a tumor-immune escape mechanism, associated with high-grade aggressive cancers with a significantly increased metastatic potential. This interesting phenomenon has not been previously documented in association with salivary gland tumors. We report, for the first time, striking neutrophil-tumor cell cannibalism associated with a high grade, aggressive and metastatic salivary duct carcinoma of the parotid gland highlighted within cytological and surgical excision pathology specimens.

Solitary Tracheobronchial Papilloma: Cytomorphology and ancillary studies with histologic correlation.

Solitary tracheobronchial papilloma (STBP) is a rare benign tumor that primarily involves the tracheobronchial tree. Human papilloma virus (HPV) infection is associated with dysplasia and a high risk of carcinoma in these lesions. The cytomorphology of STBP is not well established in the literature. Our aim is to characterize the cytomorphologic features of STBP, with histologic correlation in a series of 6 patients - 4 males and 2 females - with a mean age of 67 years (range, 53-88 years). There were 5 biopsy-proven squamous papillomas and 1 glandular papilloma. On surgical biopsy, squamous papillomas exhibited cytological atypia (4 graded mild and 1 graded moderate with focal severe dysplasia), surface erosion, and inflammation. Cytology specimens available for review included a combination of 4 fine-needle aspirations (FNAs), 2 bronchoalveolar lavages and 2 (of 3) bronchial brushings. Cytologic findings associated with squamous papillomas included atypical squamous cells and rare squamous cell resembling koilocyte in 1 bronchial brushing. Sheets of squamous cells were identified in another specimen. Several cases had a prominent background of acute inflammation, and candida was present in 1 specimen. HPV in-situ hybridization was positive in 1 case and negative in 2 cases. A p16 immunocytochemical stain performed on 1 cell block was negative. In conclusion, although STBP is a rare neoplasm, these cases may be encountered in respiratory cytology samples. FNA of papillomas yields fewer lesional cells compared to exfoliative samples. These lesions may be mistaken in cytology specimens for squamous cell carcinoma, squamous-lined cavitary lesions, an infectious (fungal) process, reactive squamous metaplasia, or oral contamination.

Endoscopic ultrasound-guided fine-needle aspiration of metastases to the pancreas: A study of 25 cases.

BACKGROUND: Metastases to the pancreas are an uncommon cause of pancreatic masses seen on endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA). The purpose of this study is to retrospectively review the cytomorphology, clinical findings, and results of ancillary studies in a large series of these unusual cases. MATERIALS AND METHODS: We searched our institution's pathology database for EUS-guided FNAs of the pancreas that were diagnostic of metastatic tumor over a 5-year period. The final cytologic diagnosis, results of ancillary studies, corresponding histological material, and clinical follow-up data were reviewed in these cases. RESULTS: A total of 1172 pancreatic EUS-guided FNAs were identified, of which 25 cases (2.1%) had a confirmed diagnosis of a pancreatic metastasis. This included 12 (48%) cases of renal cell carcinoma, 3 (12%) melanomas, 3 (12%) small cell carcinomas, and 7 (28%) other malignancies. In these metastatic tumors involving the pancreas, 20 (80%) of the lesions were solitary. Four (16%) cases had no prior history of malignancy. The average time to diagnosis of pancreatic metastasis was 5.3 years. Immunohistochemistry and special stains were performed in 22 (88%) and 9 (36%) cases, respectively. CONCLUSIONS: Our data shows that although metastases to the pancreas are rare, they can present as a solitary mass many years after the primary malignancy is diagnosed and can even be the first manifestation of an extrapancreatic primary in a small number of cases. It is important to consider the possibility of a metastatic lesion in the pancreas because this may require a different management than a primary pancreatic tumor.

The cytomorphologic spectrum of small-cell carcinoma and large-cell neuroendocrine carcinoma in body cavity effusions: A study of 68 cases.

BACKGROUND: Small-cell carcinoma (SCC) and large-cell neuroendocrine carcinoma (LCNEC) are uncommon in serous body cavity effusions. The purpose of this study is to examine the cytomorphological spectrum of SCC and LCNEC in body cavity serous fluids. MATERIALS AND METHODS: We have 68 cases from 53 patients who had metastatic SCC or LCNEC diagnoses. All cytology slides and the available clinical data, histological follow-up, and ancillary studies were reviewed. RESULTS: A total of 68 cases (60 pleural, 5 peritoneal, and 3 pericardial effusions) from 53 patients with an average age of 73 years (age range 43-92 years) were reported as diagnostic or suspicious of SCC (52 cases) or LCNEC (16 cases). The primary site was lung in 56 cases, pancreas in 6 cases, and 2 cases each from cervix, colon, and the head and neck region. Of the 68 cases, 48 cases had no history of malignancy of the same type. Ancillary studies were used in 46 cases (68%) including flow cytometric studies in 5 cases. There were three predominant cytomorphological patterns observed including small-cell clusters with prominent nuclear molding (33 cases, 49%), large-cell clusters mimicking non-small-cell carcinoma (18 cases, 26%), and single-cell pattern mimicking lymphoma (17 cases, 25%). Significant apoptosis was seen in 22 cases (33%) and marked tumor cell cannibalism was seen in 11 cases (16%). Nucleoli were prominent in 16 cases (24%). The most frequent neuroendocrine markers performed were synaptophysin and chromogranin. CONCLUSIONS: The most common cytomorphologic patterns seen in body cavity effusions of SCC and LCNEC were small-cell clusters with nuclear molding. However, in 51% of the cases either a predominant single-cell pattern mimicking lymphoma or large-cell clusters mimicking non-small carcinoma were noted. In our experience, effusions were the first manifestation of disease in the majority of patients diagnosed with neuroendocrine carcinoma. Therefore, familiarity with the cytomorphological spectrum of neuroendocrine carcinomas in fluid cytology may help in rapidly establishing an accurate diagnosis and in directing appropriate management.

Cytomorphology of Erdheim-Chester disease presenting as a retroperitoneal soft tissue lesion.

Erdheim-Chester disease (ECD) is a rare, multisystem disorder of macrophages. Patients manifest with histiocytic infiltrates that lead to xanthogranulomatous lesions in multiple organ systems. The cytologic features of this disorder are not well characterized. As a result, the cytologic diagnosis of ECD can be very challenging. The aim of this report is to describe the cytomorphology of ECD in a patient presenting with a retroperitoneal soft tissue lesion. A 54-year-old woman with proptosis and diabetes insipidus was found on imaging studies to have multiple intracranial lesions, sclerosis of both femurs and a retroperitoneal soft tissue mass. Fine needle aspiration (FNA) and a concomitant core biopsy of this abnormal retroperitoneal soft tissue revealed foamy, epithelioid and multinucleated histiocytes associated with fibrosis. The histiocytes were immunoreactive for CD68, CD163, Factor XIIIa and fascin, and negative for S100, confirming the diagnosis of ECD. ECD requires a morphologic diagnosis that fits with the appropriate clinical context. This case describes the cytomorphologic features of ECD and highlights the role of cytology in helping reach a diagnosis of this rare disorder.

Testicular touch preparation cytology in the evaluation of male infertility.

BACKGROUND: Male infertility is traditionally evaluated by tissue core biopsies of the testes. Touch preparations (TP) of these biopsies have been infrequently used. The aim of this study is to report our experience with using testicular biopsy TP for the evaluation of male infertility. MATERIALS AND METHODS: A retrospective search was performed for cases of testes biopsies with concurrent TP. These cases were evaluated for clinical information, specimen adequacy, and cytological-histological correlation. RESULTS: A total of 39 cases were identified from men with a mean age of 34 years (range 23 to 50 years). TP slides were satisfactory for evaluation in 31 (89%) cases, and less than optimal in four due to low cellularity, obscuring blood or air drying artifact. Cytopathology showed concordance with the biopsy in almost all cases. In one discordant case where the biopsies showed no active spermatogenesis, a rare sperm were identified on the TP. CONCLUSIONS: TP of the testis is a helpful adjunct to biopsy because of its ability to clearly evaluate all stages of spermatogenesis. These data demonstrate that TP cytopathology of the testes in our experience has an excellent correlation with both normal testicular biopsies and those showing pathological spermatogenesis, and in rare cases may provide added benefit in evaluating the presence of spermatogenesis for male infertility. Albeit uncommon, cytopathologists may be required to identify and evaluate spermatogenic elements in cytology specimens being submitted from men with infertility.

Cytomorphology of crystal storing histiocytosis in the breast associated with lymphoma: a case report.

Crystal storing histiocytosis (CSH) is a very rare immunoglobulin (Ig) deposition disorder in which macrophages accumulate light chains or Ig crystalline inclusions. It is frequently associated with lymphoproliferative disorders, but can be seen in some reactive conditions too. This article reports the cytomorphologic, histopathologic, and ancillary study findings of a marginal zone B cell lymphoma of the breast with CSH in a 54-year-old woman. To the best of our knowledge, this is the first report describing CSH in the breast and one of a few reports describing the cytomorphology of CSH. In breast fine-needle aspiration biopsies, CSH can be confused with benign processes such as fat necrosis and histiocytic lesions. Thus, awareness of this rare entity and its frequent association with lymphoproliferative disorders is useful in order to triage a specimen appropriately and exclude the possibility of a lymphoproliferative process.

An insight into statistical refractive index properties of cell internal structure via low-coherence statistical amplitude microscopy.

Refractive index properties, especially at the nanoscale, have shown great potential in cancer diagnosis and screening. Due to the intrinsic complexity and weak refractive index fluctuation, the reconstruction of internal structures of a biological cell has been challenging. In this paper, we propose a simple and practical approach to derive the statistical properties of internal refractive index fluctuations within a biological cell with a new optical microscopy method--Low-coherence Statistical Amplitude Microscopy (SAM). We validated the capability of SAM to characterize the statistical properties of cell internal structures, which is described by numerical models of one-dimensional Gaussian random field. We demonstrated the potential of SAM in cancer detection with an animal model of intestinal carcinogenesis--multiple intestinal neoplasia mouse model. We showed that SAM-derived statistical properties of cell nuclear structures could detect the subtle changes that are otherwise undetectable by conventional cytopathology.

Diagnostic difficulties and pitfalls in rapid on-site evaluation of endobronchial ultrasound guided fine needle aspiration.

BACKGROUND: One of the novel techniques utilizing fine needle aspiration (FNA) in the diagnosis of mediastinal and lung lesions is the endobronchial ultrasound (EBUS)-guided FNA. In this study, we describe five cases which had a discrepancy between on-site evaluation and final diagnosis, or a diagnostic dilemma when rendering the preliminary diagnosis, in order to illustrate some of the diagnostic difficulties and pitfalls that can occur in EBUS FNA. METHODS: A total of five EBUS FNA cases from five patients were identified in our records with a discrepancy between the rapid on-site evaluation (ROSE) and final diagnosis, or that addressed a diagnostic dilemma. All of the cases had histological confirmation or follow-up. The cytomorphology in the direct smears, cell block, and immunohistochemical stains were reviewed, along with the clinical history and other available information. RESULTS: Two cases were identified with a nondefinitive diagnosis at ROSE that were later diagnosed as malignant (metastatic signet-ring cell adenocarcinoma and metastatic renal cell carcinoma (RCC)) on the final cytological diagnosis. Three additional cases were identified with a ROSE and final diagnosis of malignant (large cell neuroendocrine carcinoma (LCNEC) and two squamous cell carcinomas), but raised important diagnostic dilemmas. These cases highlight the importance of recognizing discohesive malignant cells and bland neoplasms on EBUS FNA, which may lead to a negative or a nondefinitive preliminary diagnosis. Neuroendocrine tumors can also be difficult due to the wide range of entities in the differential diagnosis, including benign lymphocytes, lymphomas, small and nonsmall cell carcinomas, and the lack of immunohistochemical stains at the time of ROSE. Finally, the background material in EBUS FNAs may be misleading and unrelated to the cells of interest. CONCLUSIONS: This study illustrates the cytomorphology of five EBUS FNA cases that address some of the diagnostic challenges witnessed while examining these specimens during ROSE. Many of the difficulties faced can be attributed to the baseline cellularity of the aspirates, the bronchial contamination, the difficulty identifying neoplasms with bland cytology, the wide spectrum of diseases that can occur in the mediastinum with overlapping cytomorphologic features, the mismatch between the background material and the cell populations present, and the overall unfamiliarity with these types of specimens.

The spectrum of coincident entities with small lymphocytic lymphoma/chronic lymphocytic leukemia (SLL/CLL) diagnosed by cytology.

BACKGROUND: The cytologic diagnosis of Small lymphocytic lymphoma/chronic lymphocytic leukemia (SLL/CLL) often relies on finding a small lymphoid population with the characteristic immunoprofile by ancillary testing. There are only a few reports of other processes identified with SLL/CLL. The aim of this study was to review the fine needle aspiration (FNA) and touch prep (TP) diagnoses of SLL/CLL in order to identify any coincident entities. MATERIALS AND METHODS: We retrospectively reviewed all FNA and TP cytology cases between January 2005 and May 2009 with a diagnosis of SLL/CLL to determine the presence of any coincident process. RESULTS: We identified 29 cases, including 23 FNAs and six TPs, from 23 patients. Ancillary studies were utilized in 97% of the cases, including flow cytometry (FC, 79%), immunohistochemistry (IHC, 55%), fluorescent in situ hybridization studies (24%) and special stains (7%). Coincident entities were identified in nine cases (31%) and included seven (28%) neoplastic entities (Hodgkin lymphoma [HL], adenocarcinoma, squamous cell carcinoma, seminoma) and two (7%) non-neoplastic entities (infection and immunoglobulin containing cells). Six cases (21%) suspicious for large cell transformation were also identified. CONCLUSION: In our review of SLL/CLL, coincident entities were present in 31% of the cases and included a spectrum of non-neoplastic and neoplastic processes. FC was the most frequently utilized ancillary test, but IHC provided important information by excluding a mantle cell lymphoma or confirming a coincident process. Thus, cytomorphologic evaluation in these patients is important due to the high risk of a coincident process that may not be apparent by FC alone and may require clinical management.

Fine needle aspiration biopsy diagnosis of dedifferentiated liposarcoma: Cytomorphology and MDM2 amplification by FISH.

Lipomatous mesenchymal tumors constitute the most common type of soft tissue tumors. Well-differentiated liposarcoma (WDLS) can undergo dedifferentiation to a nonlipogenic sarcoma of variable histologic grade. In the recent literature, amplification of the murine double minute 2 (MDM2) oncogene, which has a role in cell cycle control, has been successful in distinguishing WDLS from benign lesions. We present a case of dedifferentiated liposarcoma diagnosed by fine-needle aspiration (FNA), using cytomorphology and ancillary studies (immunocytochemistry and fluorescent in-situ hybridization). An 85-year old female presented to our institution with a firm soft tissue mass of the right buttock. The FNA showed atypical spindle cells, osteoclast-like giant cells and extracellular dense matrix material. The cell block showed cellular groups of highly atypical spindle cells with osteoid and adipose tissue. Fluorescence in situ hybridization (FISH) studies performed on the cell block demonstrated amplification of the MDM2 gene. In addition, the findings were morphologically compatible with the previously resected retroperitoneal dedifferentiated liposarcoma with areas of osteosarcoma. This rare case illustrates the usefulness of FNA and ancillary studies in the diagnosis and subclassification of soft tissue tumors. To the best of our knowledge, this is the first report of MDM2 FISH positivity in a liposarcoma diagnosed by FNA.

Whole slide imaging compared with light microscopy for primary diagnosis in surgical neuropathology: a validation study.

BACKGROUND: Digital pathology practice is rapidly gaining popularity among practicing anatomic pathologists. Acceptance is higher among the newer generation of pathologists who are willing to adapt to this new diagnostic method due to the advantages offered by whole slide imaging (WSI) compared to traditional light microscopy (TLM). We performed this validation study because we plan to implement the WSI system for diagnostic services. OBJECTIVES: Determine the feasibility of using digital pathology for diagnostic services by assessing the equivalency of WSI and TLM. DESIGN: A laboratory-based cross-sectional study. SETTING: Central laboratory at a tertiary health care center. MATERIALS AND METHODS: Four practicing surgical pathologists participated in this study. Each pathologist blindly reviewed 60 surgical neuropathology cases with a minimum 8-week washout-period between the two diagnostic modalities (WSI vs. TLM). Intraobserver concordance rates between WSI and TLM diagnoses as compared to the original diagnosis were calculated. MAIN OUTCOME MEASURES: Overall intraobserver concordance rates between each diagnostic method (WSI and TLM) and original diagnosis. SAMPLE SIZE: 60 in-house surgical neuropathology cases. RESULTS: The overall intraobserver concordance rate between TLM and original diagnosis was 86.3% (range 76.7%-91.7%) versus 80.8% for WSI (range 68.3%-88.3%). These findings are suggestive of the superiority of TLM, but the Fleiss' Kappa statistic indicated that the two methods are equivalent, despite the low level of the K value. CONCLUSION: WSI is not inferior to the light microscopy and is feasible for primary diagnosis in surgical neuropathology. However, to ensure the best results, only formally trained neuropathologists should handle the digital neuropathology service. LIMITATIONS: Only one diagnostic slide per case rather than the whole set of slides, sample size was relatively small, and there was an insufficient number of participating neuropathologists. CONFLICT OF INTEREST: None.

Expression of Immune Response Markers in Arab Patients With Lung Cancer.

PURPOSE: Programmed death-ligand 1 (PD-L1) is a marker for checkpoint inhibitor use in the management of solid tumors, especially in non-small-cell lung cancer (NSCLC). Our study was aimed at determining the patterns of PD-L1 expression and cluster of differentiation 8 (CD8) immunostains in patients with NSCLC in the Arab population. METHODS: Archival tumor tissue from patients with a confirmed diagnosis of NSCLC were obtained and stained for PD-L1 with antibody 22C3, using immunohistochemistry staining and giving the tumor proportion score (TPS) as a percentage from 0%-100% of stained tumor cells. Tumors were categorized into negative expressers (TPS < 1%), low positive (TPS, 1%-49%), and high positive (TPS, 50%-100%). Correlation of expression with clinical and pathologic features, including CD8-positive (CD8+) lymphocyte density, was also analyzed. RESULTS: Two hundred patients with NSCLC were included in the study from 6 centers in Saudi Arabia and Algeria. Median age was 65 years (28-93 years), and the majority were men (75%) with stage 4 NSCLC (64%). The TPS was high in 37 patients (18%), low in 60 patients (30%), and negative in 103 patients (52%). In a univariate analysis, the following were significant predictors of any PD-L1 expression (> 1%): male sex, being Saudi national patients, high expression of CD8+, and presence of tumor-infiltrating lymphocytes. In the multivariate analysis, only high expression of CD8+ cells (≥ 2+) was significant, with an odds ratio of 4.4 (95% CI, 1.5 to 12.9; P = .003). CONCLUSION: PD-L1 expression in our population is similar to the published literature and correlated with the density of CD8+ cells. Validation of the predictive value of this marker in our population and identifying easier and reliable methods to test for it are warranted.

Malignant mixed mullerian tumor of the vagina: case report with review of the literature, immunohistochemical study, and evaluation for human papilloma virus.

The patient was a 57-year-old white woman who presented with a 3.0 x 2.0-cm partially ulcerated vaginal polyp. Histology revealed a malignant mixed mullerian tumor composed of invasive squamous cell carcinoma with deeper areas of undifferentiated pleomorphic sarcoma. Invasive carcinoma had overlying high-grade vaginal intraepithelial neoplasia (VaIN III), which contained koilocytic atypia. In situ hybridization detected high-risk human papillomavirus DNA in both the carcinoma and the sarcoma components.

Cytomorphology of a solitary left chest wall mass: an unusual presentation from unknown primary hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) may present in various ways, but only very rarely with symptoms of distant metastases or evolve from ectopic liver tissue. This report describes a case of a 62-year-old white man who was admitted for hemoptysis and a large left chest wall mass that was growing for about a year. The patient underwent Fine-needle aspiration (FNA) of the mass that revealed poorly differentiated large-cell carcinoma. A lung primary was suspected initially; however, further workup of this patient showed an elevated serum alpha-fetoprotein (AFP) level of 16,425 ng/ml. A computerized tomography (CT) scan of the abdomen showed cirrhotic liver, evidence of esophageal varices, but no evidence of a liver mass. The FNA findings were reviewed and ancillary studies were performed, including pan cytokeratin (AE1/3), Hepatocyte Paraffin 1 (HepPar-1), AFP, CD10, CD34, and polyclonal CEA. The results confirmed the diagnoses of HCC probably from occult primary or from ectopic liver tissue. The former was suggested, since serum AFP was dropped to 6,640 ng/ml following resection of the tumor. We concluded that HCC should be considered in the list of differential diagnosis of chest wall mass. HCC may present as metastatic disease from a clinically and radiologically unrecognized liver mass. FNA, coupled with ancillary studies, provides a rapid and accurate diagnostic tool in challenging cases.