Lymphadenopathy of Kimura's disease.

Kimura's disease is an important category of reactive lymphadenopathy in the Oriental population. The enlarged nodes are mostly located in the head and neck region. Salient pathological changes include florid germinal centers, Warthin-Finkeldey type polykaryocytes, vascularization of germinal centers, increased postcapillary venules in the paracortex, eosinophilic infiltration, and sclerosis. The pathology of Kimura's disease is quite different from that of angiolymphoid hyperplasia with eosinophilia (epithelioid hemangioma). Immunoperoxidase studies show IgE reticular networks in germinal centers. Nondegranulated surface IgE-positive mast cells are present in the paracortex. The authors propose that Kimura's disease represents an aberrant immune reaction to an as yet unknown stimulus. Although the individual histological features are nonspecific, the constellation of features is highly characteristic of Kimura's disease. Since lymphadenopathy can herald involvement of other tissues and the prognosis is excellent, accurate diagnosis of this disease in lymph node biopsies may spare the patients unnecessary radical surgery.

Pulmonary scar cancer. A pathologic reappraisal.

A total of 49 consecutive specimens of lung cancer were collected prospectively at surgical resection or autopsy from 40 men and nine women, aged 40-74 years. Of the 49 tumors, the gross appearance of 22 fitted the description of a scar cancer, i.e., a tumor with pleural puckering and central pigmentation. Nineteen of the "scar cancers" were peripheral (17 adenocarcinomas and two squamous cell carcinomas); three were central (one squamous cell carcinoma and two adenocarcinomas). In the 19 peripheral "scar cancers," elastic stains demonstrated the presence of collapsed, unfibrosed lung tissue at the center with traction of the overlying pleura toward it. Elsewhere in the tumor, the elastic framework was either destroyed or expanded by tumor filling the alveolar spaces. None of the "scar cancers" had a significant desmoplastic reaction that might otherwise explain the scarred appearance. It appeared that local atelectasis was solely responsible for the pleural puckering and central pigmentation. On the other hand, atelectatic lung tissue was not seen in the 27 cancers that did not have the appearance of a scar cancer. Tuberculosis was found in 10 of the 49 lung specimens. In only one specimen was the tuberculous lesion anatomically associated with the tumor. There was no evidence of pulmonary infarct in any of the specimens. The term "scar cancer" was considered inappropriate as there was no preformed fibrous tissue. The scarred appearance was thought to be the result of localized pulmonary atelectasis owing to small airways obstruction by tumor. Association with tuberculosis was considered incidental.

Expression of muscle actins in diffuse mesotheliomas.

Ultrastructural examinations have shown myofibroblastoid differentiation in sarcomatoid/desmoplastic mesotheliomas, but immunohistochemical expression of muscle actins seldom has been documented. We examined 10 sarcomatoid, 12 epithelial, and five biphasic mesotheliomas immunohistochemically for the expression of muscle-specific actin (MSA) and smooth muscle actin (SMA) and compared it with that in 12 specimens of lung cancer. All of the sarcomatoid mesotheliomas were found to be positive for both MSA and SMA. The epithelial cells in nine epithelial and two biphasic mesotheliomas were positive for MSA, but SMA was only positive in one epithelial mesothelioma. Conversely, the lung cancers were negative for both MSA and SMA in the epithelial cells, except for one specimen that was weakly positive for MSA. The stromal cells in both the epithelial mesotheliomas and lung cancers were negative for cytokeratin but were positive for MSA and SMA, whereas the sarcomatoid and biphasic mesothelioma spindle cells were positive for all three antibodies. We concluded that sarcomatoid mesothelioma was positive for MSA and SMA, which is in support of its myofibroblastic differentiation, and that positivity for MSA in some epithelial mesotheliomas might be of diagnostic value in differentiation from lung cancers.

Polymorphic reticulosis and conventional lymphomas of the nose and upper aerodigestive tract: a clinicopathologic study of 70 cases, and immunophenotypic studies of 16 cases.

Seventy patients with malignant lymphomas, including the entity known as polymorphic reticulosis (PR), involving the nose, nasal sinuses, nasopharynx, oropharynx (excluding tonsil), and larynx were studied. There were 26 cases of PR, 19 cases of lymphoma with features of PR (ML[PR]) and 25 cases of conventional lymphomas. Fourteen of the 25 conventional lymphomas were due to dissemination from distant sites. For all histologic types of primary lymphoma, the presenting symptoms were similar, and the nasal cavity was more commonly involved than the nasopharynx. Patients with PR were younger, had a higher male:female ratio, and had a better overall survival rate than patients with conventional lymphomas. Cryostat section immunohistochemistry performed on 17 samples from 16 patients showed only one B lymphoma out of 11 primary lesions; the other 10 cases and three recurrent tumors at distant sites showed phenotypic markers of T lymphocytes and natural killer cells. All three secondary tumors were of B-cell type. Of eight patients with sequential biopsies, progression to a more malignant histopathologic type was found in six. In the PR and ML[PR] biopsies, angiocentricity was detected in 11%, and angioinvasion in 22%. We could not confirm identity of PR with other angiocentric immunoproliferative lesions.

Rehydration of air-dried smears with normal saline. Application in fine-needle aspiration cytologic examination.

In fine-needle aspiration cytologic examination, nuclear features are often better assessed in hematoxylin and eosin (H and E) or Papanicolaou- (Pap) stained than Romanowsky-stained smears. However, both H and E and Pap stains require the use of immediately wet-fixed smears for cytomorphologic preservation. Some degree of air drying is usually inevitable. Placing air-dried smears in normal saline for 30 seconds before fixation in 95% alcohol is found to be a simple means of rehydrating the cells. The quality of the rehydrated smears is superior or identical to that of the immediately wet-fixed smears, provided that the period of drying does not exceed 30 minutes.

Soft tissue cysticercosis. Diagnosis by fine-needle aspiration.

Taenia solium infection is endemic in Asia and cysticercosis is not uncommon. The authors report a case of cysticercosis diagnosed by fine needle aspiration using a cell block. The authors believe it to be the first such case so diagnosed.

Blue bodies in cytology specimens in a case of pulmonary talcosis.

Unusual extracellular birefringent laminated ovoid structures are seen in bronchial brushing, aspiration, and washing specimens in a 28-year-old woman who had histologic evidence of pulmonary talcosis. Energy dispersive x-ray analysis and microchemical studies have identified them to be calcium carbonate. These structures are known as pulmonary blue bodies and are seen mainly in histologic paraffin sections. Their occurrence in cytologic preparations and association with talcosis have not been reported.

Optimal formalin fixation and processing schedule of cell blocks from fine needle aspirates.

In fine needle aspiration cytology, cell blocks may provide diagnostic information complementary or additional to that obtained from examination of cell smears. However, the morphological preservation is often unsatisfactory in cell blocks processed by routine schedules used for surgical specimens. This study investigates the effects of different formalin concentrations and processing schedules on cellular morphology. We conclude that 7.5% buffered formalin is the optimal formalin solution and a shortened processing time through xylene is desirable.

Kimura's disease: a clinico-pathological study of 21 cases and its distinction from angiolymphoid hyperplasia with eosinophilia.

Kimura's disease is a chronic inflammatory condition producing subcutaneous tumour-like nodules chiefly in the head and neck region. It is characterized histologically by lymphoid follicles, intense aggregations of eosinophils, vascular proliferation and fibrosis. Superficial lymph nodes and parotid glands are sometimes involved. The lesions may persist unchanged for years and new ones are apt to occur. Recurrences are also common. There are no systemic manifestations apart from peripheral blood eosinophilia. The lesion has been recognised as a distinct clinicopathological entity in the Far East for over 40 years. We describe 21 cases of Kimura's disease and discuss its relationship to angiolymphoid hyperplasia with eosinophilia. Although the pathogenesis and etiology of both these lesions are unknown we believe that there are sufficient significant clinical and pathological differences to justify their separation.

Primary colorectal signet-ring cell carcinoma in young patients: report of 3 cases.

Three cases of primary signet-ring cell carcinoma of the rectum are described. They accounted for 0.2% of the 1531 cases of colorectal adenocarcinoma in the 12 yr period from 1972-1983 in the University Department of Pathology at Queen Mary Hospital. The patients were young, aged 18, 24 and 27 yr respectively, in striking contrast to the mean age of 62 in patients with the usual types of colorectal cancer. They were also younger than most patients with this tumour in the literature. They presented with alteration of bowel habit, blood and mucus in stool, and weight loss. Pathological features included constrictive narrowing of the gut lumen by intestinal wall thickened by a desmoplastic reaction to diffusely infiltrating signet-ring carcinoma cells, widespread lymph node and peritoneal metastases, and absent hepatic metastasis. Microscopically, the mucosa was largely intact, but had multifocal tumour involvement. This peculiar feature was responsible for three consecutive negative biopsies in one case. Care in distinguishing it from mucinous adenocarcinoma is emphasized. All three patients presented with Dukes' C lesions. The prognosis is poor.

Modified alkali digestion method for pulmonary asbestos fibre counts.

In using the standard alkali digestion method for pulmonary asbestos fibre count, it was found that carbonaceous particles often obscured the presence of asbestos bodies (coated fibres) rendering their quantification inaccurate, particularly in lungs with a high soot particle content and a low fibre count. We applied the chloroform-ethanol separation technique from the bleaching agent digestion method to the alkali digestion method to remove the carbonaceous particles. It was found that coated fibres are much easier to visualize and count. The uncoated fibre count was nevertheless more accurate with the original method. The coated and uncoated fibre counts from 21 lung specimens were compared using both methods. The total fibre count was considered better derived from using both techniques.

Maxillary giant cell tumour associated with Paget's disease of bone.

A case involving the rare occurrence of a maxillary giant cell tumour in association with Paget's disease is reported. Surgical treatment consisted of a combined intraoral and temporal approach for tumour resection with temporalis muscle flap reconstruction of the maxilla. The postoperative course was complicated by a recurrence.

Fine-needle aspiration of gastric leiomyoblastoma metastatic to the subcutis.

Leiomyoblastomas are rare tumors, and there have been few reports on their fine-needle aspiration (FNA) cytologic morphology. We herein describe the FNA features of a gastric leiomyoblastoma with subcutaneous metastasis. The cells had eosinophilic cytoplasm and oval eccentric nuclei, occasionally with intranuclear cytoplasmic inclusions. An organoid pattern was obvious in cell block sections. The tumor was positive for vimentin but negative for desmin, S-100 protein, and the common epithelial markers. The histogenesis is discussed, as are reasons why this tumor is better termed epithelioid mesenchymal tumor.

Dithiothreitol homogenization of prefixed sputum for lung cancer detection.

The technique of chemical homogenization of sputum for cancer detection was revisited. The mucolytic agent dithiothreitol (DTT) had been used by the authors on fresh specimens. In this study, its effectiveness in homogenizing prefixed sputum was investigated. Fifty-seven positive samples were examined: 28 were prefixed with 2% carbowax in 60% ethanol and 29 in 3% carbowax in 60% ethanol. Each specimen was divided equally into three parts and homogenized immediately, 3 and 7 days later, respectively, with 0.2% (0.013 mol/L) DTT in the respective prefixative. Five samples were prefixed for 4 wk before homogenization. The homogenization time varied from 30 min to 48 hr. The cellular morphology was compared to directly smeared controls from the same samples. It was found that the cellular morphology was well preserved and best with the 3% carbowax in 60% ethanol. The specimen could be prefixed for up to 4 wk before homogenization and the homogenization process could last from 30 min to 48 hr without any damaging effect on morphology. Furthermore, screening was made easy with the mucus lysed and its obscuring effect removed and the cells concentrated and evenly distributed. The method was versatile and could be of value in enhancing the detection rate of cancer in sputum.

Fine-needle aspiration of cystic nephroma (multilocular cyst of the kidney).

Cystic nephromas are rare tumors of the kidney most commonly affecting boys or adult females. The fine-needle aspiration cytomorphology has not yet been described. A renal cystic mass in a 56 year old female was aspirated under ultrasound guidance. Papanicolaou stained smears of the cyst fluid revealed markedly atypical cells forming papillary clusters. Subsequent nephrectomy showed a typical cystic nephroma with lining epithelium resembling that seen in the aspirate. The cytomorphology of cystic nephroma has been misdiagnosed as renal cell carcinoma in the literature. Low cellularity, absence of necrosis, and paucity of single cells are features that should raise the possibility of cystic nephroma in a cystic renal mass.

Frequency of "blue bodies" in pulmonary cytology specimens.

To determine the frequency of occurrence of "blue bodies" (BBs), 2,010 pulmonary cytology specimens (1,403 sputum and 607 bronchial specimens) from 1985 were reviewed. The smears were examined microscopically by transmitted and polarized light. BBs were extracellular structures, occurring most commonly in clusters but sometimes conglomerated. With Papanicolaou stain, they had a characteristic birefringent laminated brown core and a nonbirefringent blue rim. Chemical microanalysis and energy-dispersive x-ray analysis revealed that their chemical composition was calcium carbonate. A total of 233 specimens contained BBs, with a frequency of 10.5% in bronchial specimens and 12% in sputum. Only 8.6% of the BBs had co-existent pulmonary malignancy. We concluded that BBs were common structures in pulmonary cytology and were not associated with pulmonary malignancy or pulmonary fibrosis in our series. They must be distinguished from contaminants, staining artifacts, and parasitic ova.

Distinction between colloid nodules and follicular neoplasms of the thyroid. Further observations on cell blocks.

The differentiation between colloid nodules and follicular neoplasms may be difficult in lesions yielding only microfollicles by fine needle aspiration (FNA). In a retrospective study of 35 follicular lesions, the FNA smears and cell blocks and the excised specimens were reviewed for possible distinguishing features. Columnar cells lining follicles and prominent sinusoidal stroma were seen only in follicular neoplasms; these were more easily appreciated in the cell blocks. Nuclear features and fibrosis were not helpful because they were found in both groups of lesions. Attention to the nuclear morphology was important, however, for the diagnosis of the follicular variant of papillary carcinoma. A repeat FNA might be helpful in obtaining hyperplastic papillae and fragments of dilated follicles for a diagnosis of colloid nodule in half of the cases. A few lesions with predominant microfollicular patterns were even problematic to diagnose on the excised specimens.

Homogenization of sputum with dithiothreitol for early diagnosis of pulmonary malignancies.

Homogenization of sputum with dithiothreitol (DTT) has not been used in cytology for the detection of malignant cells. We examined the efficacy of this method as compared to the conventional "pick and smear" (PS) method. Smears were prepared from sputum samples using the PS technique to act as the control. The remaining sputum was digested with an equal volume of 0.3% DTT in 70% ethanol at room temperature. The cells were washed with 35% ethanol and smears prepared. The DTT-treated specimens gave a much higher concentration of evenly distributed cells. The background was clear and the morphology comparable to that of the control. More positive cases were detected with the DTT than the conventional PS technique. Homogenization of sputum with DTT is a simple and effective method of screening for pulmonary malignancies.

Fine needle aspiration of the thyroid. Distinction between colloid nodules and follicular neoplasms using cell blocks and 21-gauge needles.

Although fine needle aspiration (FNA) of the thyroid has been found to be useful in selecting patients for surgery in most cases, the cytologic differentiation of cellular colloid nodules from follicular neoplasms has not been possible because of the scanty amount of tissue obtained by this technique and because of the infrequent preparation of cell blocks, thus precluding appreciation of the tissue architecture. Review of the histology of nodular goiters and follicular neoplasms and comparison of their morphology in smears and cell blocks from FNA specimens with the histology of the surgically excised specimens in 74 cases revealed the presence of hyperplastic papillae and fragments of dilated follicles in the aspirates of most cases of colloid nodules. These two features appear to be specific for colloid nodules and are useful for distinguishing colloid nodules from follicular neoplasms. The merits of using a 21-gauge needle and of preparing cell blocks in thyroid studies are also discussed.

Application of the immunoperoxidase technique to cell block preparations from fine needle aspirates.

Immunocytochemistry on fine needle aspiration (FNA) material has been mainly performed on cytologic preparations; there have been few reports on the use of FNA cell blocks. This study compared the intensity scores of immunoperoxidase staining on FNA cell block preparations from 21 breast, 12 thyroid and 10 lymph node aspirates with the scores on the corresponding surgically excised specimens. FNA materials for cell blocks were fixed in formalin and embedded in agar. Ten commercially available antibodies forming three panels were studied using standard peroxidase-antiperoxidase and avidin-biotin complex techniques. In general, the staining results on the FNA cell block sections agreed with those on the surgical specimens; in addition, there were fewer aberrant positive staining results and much less background staining in the cell block sections. These phenomena were most striking with the cytokeratin antibodies. It is concluded that immunoperoxidase staining on FNA cell block preparations is reliable; the advantages of the use of cell block sections as opposed to smears are discussed.