Fine-needle aspiration biopsy in the evaluation of lymphadenopathy associated with cutaneous T-cell lymphoma (mycosis fungoides/Sézary syndrome).

We studied the role of fine-needle aspiration (FNA) in the evaluation of lymphadenopathy associated with cutaneous T-cell lymphoma (CTCL) in 11 patients with lymphadenopathy and compared findings with corresponding histologic material. Molecular genetic analysis for T-cell clonality by polymerase chain reaction (PCR) was performed on all aspirates. Immunophenotyping was successful in 4 of 7 cases in which flow cytometry was attempted from the aspirated material. Cytologic evaluation of FNA samples correlated strongly with histologic rating of involvement based on numbers of atypical cerebriform lymphocytes in the nodal specimen. Of 7 nodal specimens with scattered or small groups of atypical cells in the background of dermatopathic lymphadenopathy (LN1-2), the cytologic diagnosis was interpreted as reactive in all instances. Of 4 specimens with highly suspect (LN3) or definite histologic involvement (LN4), the cytologic diagnosis was likewise suspect or malignant. The correlation between molecular genetic studies on FNA samples and studies on tissue was not significant; in 2 cases, a T-cell clone was detected in the nodal tissue sample but not in the FNA sample, suggesting undersampling. A T-cell clone was detected by PCR in 5 of 7 nodal specimens judged reactive by FNA biopsy or histologic assessment. FNA for cytologic and molecular genetic analysis is a useful method to evaluate lymphadenopathy associated with CTCL and may obviate the need for surgical biopsy.

The case for cytologic follow-up after LEEP.

OBJECTIVE: To examine our loop electrocautery excisional procedure (LEEP) biopsy experience to assess the incidence of abnormal follow-up and relate this to margin status. STUDY DESIGN: Records of 162 LEEP procedures performed between January 1992 and April 1994 were reviewed to evaluate margin readability and status. All follow-up cytologic or histologic specimens were examined. RESULTS: After a mean 10.9-month follow-up, of 162 cases, 67 had a negative study (41.4%). Fifty-four (33.3%) had an abnormal result, with high grade squamous intraepithelial lesion (HSIL) in 16 cases (13.2%) of all LEEPs with follow-up, low grade squamous intraepithelial lesions in 27 (22.3%) and squamous atypia in 11 (9.1%). On microscopic review of these 54 cases, 37 had a readable margin (68.5%); of these readable margins, 12 (32.4%) were positive. Forty-one cases (25.3% of all LEEPs) had no follow-up study. CONCLUSION: The high incidence of HSIL after LEEP highlights the need for vigilant follow-up. Prediction of follow-up by margin status is dubious. Thermal artifact makes the margin uninterpretable in many cases, and two-thirds of cases with abnormal follow-up occurred where the LEEP margin was negative. Our finding of no follow-up for 25% of LEEPs performed is particularly disturbing in light of these results.

Cervical endometriosis: a potential pitfall in the evaluation of glandular cells in cervical smears.

The use of the cytobrush and other endocervical sampling instruments has resulted in an increasing rate of detection and attention to glandular abnormalities of the cervix. Lesions that have been identified as look-alikes to endocervical gland dysplasia or adenocarcinoma in situ include squamous carcinoma in situ, atypical squamous metaplasia involving glands, and tubal metaplasia. In this report, we describe our recent experience with another condition that can mimic glandular abnormalities--cervical endometriosis. An in-depth review of the features seen in cervical smears from patients with cervical endometriosis is presented.

The detection of endocervical gland involvement by high grade squamous intraepithelial lesions in smears prepared from endocervical brush specimens.

The cytologic features of squamous cell carcinoma in situ with endocervical gland involvement have been described in cervical smears. We evaluated the presence of two types of cellular fragments in 43 cervical smears of high grade squamous intraepithelial lesions (HGSIL) to assess their ability to predict glandular involvement by HGSIL in subsequent cone biopsies. An endocervical brush was used to obtain all endocervical specimens. Of 16 cases without glandular involvement, fragments were present in 13 smears. Of 27 cases with glandular involvement, fragments were absent in 11 smears. No statistical association was identified between the presence of abnormal cellular fragments on cervical smears of HGSIL and endocervical gland involvement on cone biopsies.

Expression of estrogen and progesterone receptors in cytologic specimens using various fixatives.

Estrogen and progesterone receptor reactivity may be useful in identifying possible primary sites of metastatic disease or directing therapy in tumors of the female genital tract, including breast, ovary, and endometrium. Various methods have been described for the immunocytochemical evaluation of estrogen receptor (ER) and progesterone receptor (PR) status of cytologic specimens but our results have been variable. We evaluated the effectiveness of various fixatives [cytospin collection fluid, Shandon, Pittsburgh, PA (SH); ethanol (ETH); and formalin (FOR)] for fixation of smears (SM) and cell block (CB) material. The percentage and intensity of tumor nuclei of SM, CB, and tissue sections (TS) stained for ER and PR by the avidin-biotin-peroxidase complex technique were compared. Samples were considered ER or PR positive when > or = 20% of tumor nuclei were stained. The sensitivity of ER analysis of SMs and CBs in each fixative compared to formalin-fixed paraffin-embedded tissue sections were as follows: SM (SH) 88%, SM (ETH) 14%, CB (SH) 58%, CB (ETH) 43%, and CB (FOR) 70%. The sensitivity of PR determination on SMs and CBs was SM (SH) 71%, SM (ETH) 6.0%, CB (SH) 25%, CB (ETH) 33%, CB (FOR) 80%. These findings indicate that of the fixatives evaluated for ER analysis, SMs fixed in SH provided the best results. For PR evaluation, CBs fixed in FOR gave the best results.

Bcl-2 oncoprotein is widespread in lymphoid tissue and lymphomas but its differential expression in benign versus malignant follicles and monocytoid B-cell proliferations is of diagnostic value.

The distribution of Bcl-2 oncoprotein was studied immunohistochemically in formaldehyde-fixed and paraffin-embedded reactive and neoplastic lymphoid tissue. The potential of Bcl-2 for the differential diagnosis of follicular lesions was emphasized, and the results on follicular lesions were correlated with those of polymerase chain reaction (PCR) assay of the immunoglobulin heavy chain gene rearrangement. In hyperplastic lymphoid tissue, Bcl-2 reactivity was widespread, including germinal center surroundings, scattered cells within the germinal centers, and the T-cell areas in general. Distinctively negative lymphoid populations included the majority of germinal center cells, and the negative staining pattern was maintained in cases of florid hyperplasia. In contrast, follicular lymphoma cells were consistently Bcl-2 positive. The immunohistochemical Bcl-2 reactivity of lymphoma follicles correlated with the clonal PCR amplification pattern of the immunoglobulin heavy chain gene; all Bcl-2-negative hyperplasias revealed a non-clonal pattern. Clusters of monocytoid B cells were Bcl-2 negative, whereas monocytoid B-cell lymphomas and closely related MALT lymphomas were positive. All other small cell non-Hodgkin's lymphomas of B-cell types showed nearly uniform Bcl-2 reactivity, whereas large cell B-cell lymphomas were variably positive (74%). In Hodgkin's cells, Bcl-2 reactivity was seen in the neoplastic populations of most cases of nodular sclerosis and mixed cellularity types, whereas the L&H and Reed-Sternberg cells in lymphocyte predominance Hodgkin's disease were negative in most cases. Bcl-2 immunohistochemistry thus appears very valuable in the differential diagnosis of follicular hyperplasia and neoplasia, and it may help to distinguish between reactive and neoplastic monocytoid B cells. However, Bcl-2 immunohistochemistry is not useful in the subtyping of B-cell lymphomas.

Bilateral breast carcinoma: mammographic and histologic correlation.

PURPOSE: To determine the mammographic, histologic, and clinical features of bilateral breast cancer. MATERIALS AND METHODS: Pre-biopsy mammograms of 67 patients with bilateral carcinoma were reviewed. Lesions were synchronous in 35 patients and metachronous in 32. Mammographic appearance, lesion size and location, and bilateral similarities were evaluated. Axillary nodal status was noted. These characteristics were compared with those of unilateral cancers. RESULTS: Of 58 mammographically evident lesion pairs, 31 involved the same quadrant. Of the total 67 lesion pairs, 24 pairs were similar in appearance, and 15 had both mirror image location and a similar appearance. Of 17 lesion pairs considered to represent a single primary carcinoma with metastases to the contralateral breast, eight had a similar mirror image appearance and five had mirror image location and a similar mirror image appearance. The second cancer of metachronous pairs was smaller, with less frequent axillary nodal involvement. CONCLUSION: The appearance of bilateral breast cancer does not differ from that of unilateral carcinoma. Bilateral breast carcinomas frequently demonstrate a similar mammographic appearance and mirror image location.

Solitary fibrous tumor: histological and immunohistochemical spectrum of benign and malignant variants presenting at different sites.

Twenty-nine tumors (from 26 patients, including two with recurrent disease) diagnosed as solitary fibrous tumor (SFT) of the pleura (n = 23), mediastinum (n = 4), abdominal cavity (n = 1), and parotid gland (n = 1) were studied immunohistochemically. Three histologically malignant tumors showed areas of high cellularity and mitotic activity (more than 4 mitoses/10 high-power fields) with features resembling malignant fibrous histiocytoma, malignant hemangiopericytoma, or fibrosarcoma, together with areas typical of benign solitary fibrous tumor. Formaldehyde-fixed, paraffin-embedded tissues and avidin-biotin-complex immunostaining were used. All of the tumors showed vimentin positivity and did not stain for cytokeratin, glial fibrillary acidic protein, or muscle cell markers, except for focal desmin reactivity in seven tumors, mostly seen in frozen sections, and focal keratin reactivity in one histologically malignant tumor. The neoplastic cells were positive for CD34 and negative for CD31; these patterns also were seen in the three histologically malignant cases. In nine of the cases acetone-fixed frozen sections showed variable focal positivity for neurofilament proteins of 68 kd. We conclude that SFT is a neoplasm of fibroblasts/primitive mesenchymal cells with features of multidirectional differentiation. We also report the finding of a novel site for SFT, the parotid gland.

Predictors of human papilloma virus in patients with keratinization.

Given the prevalence of human papilloma virus (HPV) infection, an attempt was made to determine whether certain factors such as keratinization and/or squamous atypia are associated with its development. Review of our gynecologic cytology files from 1989 yielded 1,615 specimens showing parakeratosis and/or hyperkeratosis, without cytologic evidence of HPV. Concomitant diagnoses included no atypia [keratinization only (KO)], inflammatory squamous atypia (ISA), and squamous atypia (SA). Morphologic follow-up including repeat cytology or biopsy was available for 916 cases, 92 (10.0%) of which possessed changes of HPV. For any case with both cytologic and biopsy evidence of HPV, only the biopsy result was tabulated. HPV on follow-up examination was detected in 52 (6.7%) of the 764 cases with KO; in 20 (20.8%) of the 96 cases with keratinization and ISA (KISA); and in 20 (35.7%) of the 56 cases with keratinization and SA (KSA). The definitive diagnosis of HPV was based on previously described features (Gupta, In: Comprehensive Cytopathology, Philadelphia: WB Saunders, 1991:133-140) including nuclear enlargement with nuclear membrane irregularities in combination with sharply demarcated paranuclear cytoplasmic clearing. Affected cells have rounded borders. Binucleated cells are not uncommon. The increasing percentage of HPV from KO to KISA to KSA is not necessarily surprising. However, mathematical analysis revealed statistically significant differences in the development of HPV in each of the 3 groups: KISA vs. KO (P < 0.001), KSA vs. KO (P < 0.001), and KSA vs. KISA (P < 0.05). Therefore, a cytologic diagnosis of keratinization with ISA or especially SA should warrant closer follow-up than that of KO.

Fundamentals of bone marrow examination.

Bone marrow evaluation is an important and effective way of diagnosing and evaluating primary hematologic and metastatic neoplasms as well as nonhematologic disorders. Many variations exist for obtaining marrow samples (sites, instruments, techniques); however, the method outlined in this article has proven reliable. Complete evaluation of bone marrow samples should include a brief patient history, pertinent laboratory data, peripheral blood films, bone marrow aspirate smears and sections, and biopsy imprints and sections. Routine examination of the bone marrow as described previously is usually adequate for interpretation. However, application of additional studies using cytochemical, immunocytochemical, immunohistochemical, cytogenetic, and molecular techniques may prove to be of critical importance in the diagnosis of hematologic malignancies.

Abdominal iron distribution in sickle cell disease: MR findings in transfusion and nontransfusion dependent patients.

OBJECTIVE: Our goal was to determine the difference in iron distribution between transfusion dependent (TD) and nontransfusion dependent (NT) patients with sickle cell disease (SCD). MATERIALS AND METHODS: The T2-weighted and T2*-weighted abdominal MR images in nine cases of homozygous SCD were reviewed to determine the distribution of low signal from iron in five TD and four NT patients. RESULTS: All eight patients with visualized spleens had decreased splenic signal intensity. One patient who had no history of splenectomy had no visualized splenic tissue. The majority of both groups had renal cortex of low signal intensity that was attributable to iron deposition from intravascular hemolysis and was not correlated with clinical renal abnormalities. None of the NT group had liver or pancreas of low signal intensity, while all five TD patients had decreased liver signal intensity and three of five had decreased pancreatic signal intensity. CONCLUSION: Decreased pancreatic signal intensity can occur in TD patients, perhaps suggesting total body iron overload. Nontransfusion dependent sickle cell patients usually have normal hepatic signal intensity and do not have total body iron overload, even in the presence of renal and splenic iron deposition.

Fine-needle aspiration of a periurethral Teflon-filled cyst following radical prostatectomy.

Periurethral Teflon injections are being used increasingly for the treatment of urinary incontinence after radical prostatectomy. We report a case of a man who developed increasing obstructive urinary symptoms and stress incontinence following radical retropubic prostatectomy. Six months earlier, he had undergone periurethral Teflon injections. On transrectal ultrasound and magnetic resonance imaging, a 3.2-cm cystic lesion was noted at the prostatic bed near the bladder neck where the Teflon had been injected. Ultrasound-guided transperineal fine-needle aspiration of the cyst yielded a specimen with numerous birefringent crystalline Teflon particles. Although previous reports have described granulomatous tissue reaction, no multinucleated giant cells were present to suggest granuloma formation. To our knowledge, this is the first reported case of Teflon cyst formation following periurethral Teflon injections. The patient's history, imaging studies, cytopathology, and review of the literature are presented in this report.