Analysis of ret/PTC gene rearrangements refines the fine needle aspiration diagnosis of thyroid cancer.

Papillary carcinoma (PC) represents the most common malignancy of the thyroid gland. Therefore, the assessment of fine needle aspiration biopsies of thyroid nodules rests heavily on the identification of nuclear features of PC. The ret/PTC oncogene, formed by several gene rearrangements, is specific for PC among thyroid tumors. In this study we examined thyroid aspirates for the presence of ret/PTC gene rearrangements by RT-PCR and Southern hybridization. We prospectively collected thyroid aspirates in Cytolyt solution and prepared slides for cytological examination using the ThinPrep method. All remaining material was then used for nucleic acid extraction with subsequent RT-PCR for the housekeeping gene PGK-1 to ensure ribonucleic acid integrity, for thyroglobulin to ensure the presence of follicular epithelial cells, and for the three most common ret/PTC gene rearrangements (ret/PTC-1, -2, and -3). The results of the first 73 cases with surgical follow-up were correlated with the cytological diagnosis and final histopathology. ret/PTC gene rearrangements were detected in 17 of 33 samples (52%) that were PC on histopathology; the presence of gene rearrangements was confirmed by molecular analysis of corresponding surgically resected frozen tissue. There were no false positives. The identification of ret/PTC gene rearrangements refined the diagnosis of PC in 9 of 15 specimens (60%) that would otherwise have been considered indeterminate and in 2 of 6 that were considered insufficient for cytological diagnosis. The results indicate that RT-PCR for ret/PTC is a specific marker that can be applied to fine needle aspiration biopsies and improves the diagnosis of malignancy when used as an adjunct to traditional cytology.

Correlation of p53 mutations in ThinPrep-processed fine needle breast aspirates with surgically resected breast cancers.

Mutations of the p53 gene are one of the most common genetic changes found in cancer; their presence may be prognostic and even influence treatment for breast cancer. In this study, we investigated whether DNA could be extracted from the residual cells left in ThinPrep-processed breast fine-needle aspirates and whether p53 gene changes could be detected in the DNA. The results were then correlated with DNA extracted from the matched formalin-fixed, paraffin-embedded, surgically resected breast cancer when available. DNA was successfully extracted from 54 of 62 aspirates and all 31 surgical specimens. p53 gene mutations were detected in 10 of the 54 cytology specimens (18.5%) and consisted of base pair substitutions or deletions. Silent or intronic p53 changes were found in five additional aspirates. One of the aspirates had two gene alterations, resulting in a total of six gene changes. Five of these changes were located in introns 6 or 9 and the sixth was a silent (no amino acid change) change in exon 6. p53 Polymorphisms were detected in nine aspirates (16.3%) and were located in codon 47 (one aspirate), codon 72 (six aspirates), and codon 213 (two aspirates). All cases with surgical material available showed identical p53 mutations, alterations, and polymorphisms in the resected tumors compared with those detected in the corresponding aspirates. The results of this study show that DNA suitable for analysis of p53 gene sequence changes can be successfully extracted from ThinPrep-processed breast fine-needle aspirates, and that identical alterations are detected in both the cytology and surgical specimens.

Estrogen and progesterone receptor contents in ThinPrep-processed fine-needle aspirates of breast.

This study was undertaken to assess the potential value of ThinPrep-processed (Cytyc, Boxborough, MA) smears from malignant breast fine-needle aspirates (FNAs) for the determination of estrogen receptor (ER) and progesterone receptor (PR) status. The ER and PR content of 142 malignant FNAs were compared with the results of the surgically excised tumors in which the assay was done by enzyme immunoassay in 97 cases or by immunohistochemistry in 45 cases. Monoclonal antibodies directed against ER-1D5 (Dako, Carpinteria, CA) and PR-1A6 (Dako) were used with the antigen retrieval technique. By using enzyme immunoassay and immunohistochemistry as standards, the overall accuracy for ER was 97% and for PR was 89%. The results of this study show that the ThinPrep smear with microwave antigen retrieval pretreatment is a reliable method and a suitable alternative for hormone receptor analysis in breast carcinoma.

Breast fine-needle aspiration. A comparison of ThinPrep and conventional smears.

Fine-needle aspiration (FNA) of the breast has been used in our institution since 1969. In August 1993, ThinPrep (Cytyc Corp, Boxbotough, MA) processing of breast FNA biopsy specimens was introduced. Comparing conventionally prepared breast FNA specimens (21,193 cases) with ThinPrep processed material (7,903 cases) shows a decrease in the unsatisfactory rate with the ThinPrep processing (29.5% to 27.7%) with no significant change in sensitivity (84.4% vs 86.3%) or positive predictive value (96.5 vs 95.0%). However, there is a slight decrease in specificity (98.6% vs 96.5%) and negative predictive value (91.1% vs 88.0%) with the ThinPrep specimens. The results span 28 years, during which time the breast cancer population has changed, with a higher prevalence of malignancy in the last decade of our study. When the 4 most recent years of conventional cytology are compared with the 4 years of ThinPrep processing, there is no significant difference in diagnostic accuracy. The results of the present study show that the ThinPrep processing technique provides an effective method for preparing breast FNA. specimens.

Rhabdomyosarcoma with rhabdoid-like features.

We describe an unusual case of a rhabdomyosarcoma (RMS) in that it had rhabdoid-like cells histologically and occurred in a female who had undergone bone marrow transplantation for chronic myelogenous leukemia. The tumor was composed of loosely cohesive cells with abundant eosinophilic cytoplasm and exhibited PAS-negative paranuclear inclusions. The tumor cells had positive vimentin, muscle-specific actin, sarcomeric actin and desmin immunoreactivity. Ultrastructurally, the tumor cells contained aggregates of thin and thick filaments. In situ hybridization did not detect human papillomavirus or cytomegalovirus DNA, or EBV DNA or RNA. The tumor fulfilled the current criteria for a diagnosis of RMS; however, it could not be further classified. The tumor appears to have a good prognosis as there has been no evidence of recurrence five years after resection. As this is the first case report, to our knowledge, of this type of tumor following bone marrow transplant, the significance of this association is not yet clear.

Value of electron microscopy and immunohistochemistry in the diagnosis of soft tissue tumors.

Light microscopy alone is often insufficient to type a soft tissue tumor. In this study 142 consecutive soft tissue tumors (benign or malignant), for which both electron microscopy (EM) and immunohistochemistry (IHC) had been performed, were reviewed to assess the contribution of these two modalities to making the final diagnosis. A tentative diagnosis (58 cases) or differential diagnosis (84 cases) was made following light microscopical examination. Ultrastructural and immunohistochemical features were then reviewed. Overall, EM more often contributed to diagnosing the tumor type than IHC (80 vs. 65%), with a statistically significant difference (p = .001). This was most apparent in high-grade sarcomas (grade III); the contribution of the two modalities was similar in benign and low-grade malignant tumors. IHC more often than EM (33% vs 22%) did not provide information to aid in typing of the tumor. However in 47% of the cases in which one of the two modalities was noncontributory, the other technique was helpful in reaching a diagnosis. These findings suggest that both IHC and EM are necessary to properly evaluate soft tissue tumors.

Primary leiomyosarcoma of bone: report of seven cases and review of the literature.

OBJECTIVE: To report seven cases of intraosseous leiomyosarcoma and compare them with the cases in the literature. DESIGN: Retrospective review of histologic, immunohistochemical, and ultrastructural features. Tumors were examined immunohistochemically for proliferative activity and p53 protein accumulation. SETTING: Mount Sinai Hospital, University of Toronto, Ontario, Canada. RESULTS: The histologic grade of the tumors ranged from I to III. All tumors showed vimentin and muscle-specific actin immunoreactivity and smooth muscle differentiation ultrastructurally. Proliferative activity was demonstrated immunohistochemically in five of the seven cases. Only one tumor showed p53 protein accumulation. CONCLUSION: Primary leiomyosarcoma of bone is an aggressive tumor with light microscopic, ultrastructural, and immunohistochemical features similar to leiomyosarcoma of soft tissue. The proliferative activity of these tumors does not appear to correlate with the histologic grade. p53 protein accumulation as detected by immunostaining is not common in these tumors.

Immunocytochemical staining on ThinPrep processed smears.

This study reports our first-year experience in the immunocytochemical staining of specimens prepared by the ThinPrep processor. The avidin-biotin-complex technique was applied to smears of 70 cytological specimens, including fine-needle aspiration samples from various sites (56 specimens), body fluids (13 specimens) and urine (one specimen). The specimens were collected in CytoLyt solution to lyse red blood cells and then resuspended in the processing solution. The smears were made by the processor and fixed in 95% alcohol. The panel of antibodies used included alpha-fetoprotein, carcinoembryonic antigen, cytokeratin, chromogranin A, HMB-45, beta-human chorionic gonadotropin (beta-HCG), Kappa, Lambda, Ki-1, leucocyte common antigen, L26, neuron-specific enolase, 013, prostatic acid phosphatase, prostatic-specific antigen, S100, thyroglobulin, UCHL-1, and vimentin. The various antigens could be easily demonstrated in the ThinPrep smears, except for some lymphoma markers. Nonspecific background staining caused by blood and proteinaceous debris was virtually absent. In general, the monolayer preparation made the interpretation easier than conventional preparations. The only problem with this technique was in the classification of lymphomas where immunotyping was inconclusive. Our preliminary results indicate that ThinPrep smears are suitable for immunocytochemical studies, except for the classification of lymphomas.

Secondary malignancy of the thyroid gland and its management.

BACKGROUND: Secondary cancer of the thyroid gland is widely acknowledged as infrequent but is a persistent problem requiring ongoing awareness, particularly with respect to clinical recognition and treatment. METHODS: From 1978 to 1993, a 15-year period, patients demonstrating secondary involvement of the thyroid gland as a surgical problem were collected and analyzed with regard to pathology, demography, behavior of primary and secondary disease, treatment, and patient outcome. RESULTS: In the 15-year span, 11 patients with secondary involvement of the thyroid gland were recognized, consisting of 3 men and 8 women with primary lesions occurring in oral cavity, esophagus, stomach, colon, pancreas, breast, skin, unknown, kidney, and lung. Needle biopsy produced a 90% malignancy rate but in only half of such cases was the diagnosis specific for secondary malignancy. Eight of 11 underwent palliative surgery, usually total thyroidectomy. No patient survived > 2 years. There was no undue surgical morbidity. One patient died of pulmonary embolus postoperatively. CONCLUSIONS: Secondary cancer of the thyroid is rare and can be detected by fine-needle aspiration biopsy in the face of clinical findings. Where indicated, palliative thyroidectomy can be effective, because other methods of treatment appear ineffective.

Intraosseous malignant peripheral nerve sheath tumor. Report of a case and review of the literature.

We report a case of a malignant peripheral nerve sheath tumor arising in the distal femur of a 28-year-old man who had no stigmata of von Recklinghausen's disease. Roentgenograms and computed tomographic scans of the distal femur showed a single lytic intraosseous lesion with minimal soft tissue extension. Light microscopy demonstrated a tumor composed of spindle cells with myxoid areas. There was some nuclear pleomorphism and mitotic activity. The tumor cells were immunoreactive for S100 protein and neuron-specific enolase. Ultrastructurally, there were cells with long processes, which were focally invested by basal lamina. Some cells had numerous micropinocytotic vesicles. The tumor recurred in the femur 15 months following the initial curettage. Computed tomographic scan of the lungs at that time showed a nodule, which has since enlarged. Primary osseous malignant peripheral nerve sheath tumors are uncommon. A literature review revealed only 18 previous cases, the majority of which occurred in the mandible or maxilla. This is a rare case of intraosseous malignant peripheral nerve sheath tumor of a long bone, with both immunohistochemical and ultrastructural confirmation of nerve sheath differentiation.

Ultrasonography and ultrasound-guided fine-needle aspiration biopsy of head and neck lesions: a surgical perspective.

A head and neck ultrasound-guided fine-needle aspiration clinic was set up to determine the role of ultrasound and ultrasound-guided fine-needle aspiration in the evaluation of patients with lesions in this region. One hundred ninety-five lesions were biopsied by ultrasound-guided fine-needle aspiration in 203 patients. Ultrasound detected 2 or more lesions in 14 (48%) of 29 patients with a clinically solitary thyroid nodule. Three (8.8%) of 34 lesions thought to be within the parotid gland were determined to be external. A pronounced learning curve was evident in the technique of ultrasound-guided fine-needle aspiration, particularly for nonpalpable disease. Adequacy of sampling for each 3-month period was 71%, 89%, and 94%, respectively. Seventy-four percent of central aspirations were satisfactory compared to 54% of peripheral aspirations. Ultrasound-guided fine-needle aspiration did not alter the clinical staging of metastatic neck disease in 8 patients having 10 neck dissections but proved useful in detecting nodal recurrence in 3 irradiated necks that did not proceed to surgery. The smallest node to harbor malignancy had 4-mm maximal axial diameter. We conclude that ultrasound and ultrasound-guided fine-needle aspiration are valuable adjuncts to the clinical examination.

Metastatic adamantinoma diagnosed by fine-needle aspiration biopsy of the lung.

We report two cases of metastatic adamantinoma to the lung diagnosed by FNAB. The cytologic appearance of the smears of each case was homogenous, containing small round and spindle cells with indistinct cytoplasm. The nuclei had delicate nuclear membranes, with finely dispersed chromatin and occasional micronucleoli. No pleomorphism was noted. Immunocytochemistry exhibited positive staining for keratin and vimentin. EM examination revealed numerous tonofilaments and well formed desmosomes. The cytologic diagnosis of metastatic adamantinoma can be made with the knowledge of a previous history of adamantinoma of bone, the comparison of the metastatic tumor with the original bone tumor, and the awareness of the long latency of the metastases. Immunocytochemistry and EM are needed to substantiate the diagnosis.

Ultrasound-guided fine-needle aspiration biopsy in the management of thyroid disease.

During a 23-month period, 59 patients were referred for ultrasound (US)-guided fine-needle aspiration biopsy (FNAB) of the thyroid gland because of inadequate orthodox (office) FNAB, a clinically small lesion, or an occult lesion. Seventy percent of the group (41 patients) was referred for surgery, which revealed cancer in 37% of patients, adenoma in 19%, and benign disease in 44%. US-guided FNAB yielded false-positive reports in 0% of patients, false-negative reports in 5% to 12%, and inadequate aspirates in 32%. The US-guided FNAB technique had a sensitivity of 60% to 90%, a specificity of 100%, a positive predictive value of 100%, a negative predictive value of 80%, and an accuracy of 85%. US-guided FNAB provides cytologic information in 60% of patients in whom a diagnosis cannot be established by orthodox (office) means, thus enhancing the diagnostic ability of clinicians who can recommend a treatment program with confidence.

Correlation of cytologic and histologic features in variants of papillary carcinoma of the thyroid.

Different morphologic variants have been described for papillary carcinoma of the thyroid, but little emphasis has been placed on their cytologic patterns. We studied fine needle aspiration (FNA) smears and histologic sections from 48 cases of papillary carcinoma, including 24 of the usual type, 13 of the follicular variant, 7 of the encapsulated variant and 4 of the tall cell variant, in an attempt to correlate the cytologic features and the different histologic variants. Single cells, monolayers and papillary fragments were present in all the variants. The presence of follicles was not restricted to the follicular variant. Nuclear grooves and cytoplasmic pseudoinclusions were present in most of the cases, with nuclear grooves the most common finding in all the variants (92.3-100%). Psammoma bodies were an infrequent finding (0-25%) and were absent from the follicular variant. Colloid was present in all the variants and was a frequent finding in the follicular variant (84.6%). The findings suggest that the exact histologic variant of papillary carcinoma cannot be predicted from the appearance of the fine needle aspirate.

Simple miniblock technique for cytology.

Seventy cytology specimens, including fine-needle aspirates from various sites, body effusions, and bronchoalveolar lavages were prepared with a cell block system. This technique, which uses a gelling reagent and a setting reagent to increase the recovery of material, is described in detail. Fifty-four cases had adequate material. To assess the efficacy of the technique, miniblock sections were compared with smears. In 23 cases (43%), the sections provided additional information for a definite diagnosis. The technique allows the recovery of minute cellular material and is valuable for histochemical and immunohistochemical studies.

Metastatic squamous carcinoma presenting as a neck cyst. Differential diagnosis from inflamed branchial cleft cyst in fine needle aspirates.

Fine needle aspirates (FNAs) from five cases of cystic squamous carcinoma metastatic to cervical lymph nodes were compared to those of five cases of branchial cleft cyst to determine whether these lesions could be differentiated by cytologic examination. Squamous carcinoma could be recognized by the following cytologic features: increased nuclear/cytoplasmic ratio, irregularity of nuclear outline and nuclear hyperchromatism. The branchial cleft cysts showed essentially benign squamous cells with only mild nuclear atypia. The background of the malignant aspirates showed more necrotic debris but fewer polymorphonuclear cells than that of the branchial cleft cysts. By adhering to these cytologic criteria a definitive diagnosis is possible; it should be confirmed by histologic examination.

Value of fine-needle aspiration in the diagnosis of Hürthle cell neoplasms.

The cytologic and histologic slides on all patients with a diagnosis of Hürthle cell tumor at Mount Sinai Hospital during the last 12 years were reviewed. There were 67 Hürthle cell tumors of which 15 (22%) were malignant. Four carcinomas (27%) occurred in a background of thyroiditis. Forty-three patients with Hürthle cell tumors had undergone preoperative fine-needle aspiration, of which 31 had satisfactory aspirates. For Hürthle cell neoplasia, fine-needle aspiration cytology had a sensitivity of 83.8% (26 of 31) and positive predictive value of 93% (26 of 28), provided that the aspirate was of adequate cellularity. All 3 cases predicted as Hürthle cell carcinoma on the basis of cellular and nuclear atypia were correctly predicted, but 3 carcinomas composed of bland cells were incorrectly predicted as adenomas. We conclude that aspiration cytology can differentiate nonneoplastic from neoplastic Hürthle cell lesions with high accuracy, but that the differentiation between benign and malignant lesions is less reliable.

Observations on the natural history of a parotid epithelial-myoepithelial carcinoma of intercalated ducts.

A case report of a parotid epithelial-myoepithelial carcinoma (EMC) of intercalated ducts is presented. There were no changes in clinical characteristics or growth over a four-year period as documented by repeated clinical examination and serial ultrasounds. This neoplasm may be mistaken for an adenoid cystic carcinoma on fine needle aspiration and is believed to represent an adenocarcinoma of low malignant potential. The imperceptible growth of this epithelial-myoepithelial carcinoma is in accord with a low malignant potential.

Metastasizing neuroendocrine tumor of unknown origin found in cervical lymph nodes: a case report.

Neuroendocrine tumors are a diverse category of tumors that have been known to produce biologically active amines and ectopic hormones of various types. Numerous metastasizing primary lesions have been identified, however, the head and neck region is not a common site for them. Even less common than these are head and neck metastatic sites without an identifiable primary lesion. We report a case of a metastatic neuroendocrine tumor, where the primary site eluded detection despite an extensive battery of investigations.

Surgical treatment in non-neoplastic parotid disease: indications and results.

Non-neoplastic disease of the parotid gland is an important entity, requiring differential diagnosis and management. The incidence of non-neoplastic parotid disease (NNPD) is increasing and makes up about 25% of cases for which parotidectomy is indicated. NNPD can be categorized as type I (asymptomatic soft diffuse enlargement or circumscribed firm nodular enlargement) or type II (inflammatory lesions with recurrent pain and swelling, obstructive or nonobstructive). Concern over possible malignancy is highest in type I nodular lesions and least in type II lesions. Operative treatment may be indicated for exclusion of tumour, relief of recurrent pain and swelling and patient anxiety. In 62 patients with NNPD who were operated on, the relevant clinical factors included radiation, diabetes, tuberculosis, Sjögren's syndrome and pulmonary sarcoidosis. Superficial parotidectomy was effective, being associated with low morbidity, and can be recommended as acceptable treatment, providing there is a complete patient history and operation is carried out by a surgeon experienced in parotid surgery.