Respiratory Cytology--Current Trends Including Endobronchial Ultrasound-Guided Biopsy and Electromagnetic Navigational Bronchoscopy: Analysis of Data From a 2013 Supplemental Survey of Participants in the College of American Pathologists Interlaboratory Comparison Program in Nongynecologic Cytology.

CONTEXT: Nongynecologic cytology (NGC) practices are expanding in relationship to historical gynecologic cytology screening programs. Bronchopulmonary cytology is experiencing an evolution regarding new procedural types. The College of American Pathologists (CAP) tracks practice patterns in NGC by developing questionnaires, surveying participants, and analyzing respondent data. OBJECTIVE: To analyze responses to a 2013 CAP supplemental survey from the Interlaboratoy Comparison Program on bronchopulmonary NGC. DESIGN: The "NGC 2013 Supplemental Questionnaire: Demographics in Performance and Reporting of Respiratory Cytology" was mailed to 2074 laboratories. RESULTS: The survey response rate was 42% (880 of 2074) with 90% of respondents (788 of 880) indicating that their laboratories evaluated cytology bronchopulmonary specimens. More than 95% of respondents indicated interpreting bronchial washings (765 of 787) and bronchial brushings (757 of 787). A minority of laboratories (43%, 340 of 787) dealt with endobronchial ultrasound-guided samples, and an even smaller fraction of laboratories (14%, 110 of 787) saw cases from electromagnetic navigational bronchoscopy. Intraprocedural adequacy assessments by pathologists (and less often by cytotechnologists or pathologists-in-training) were routinely performed in percutaneous transthoracic aspiration cases (74%, 413 of 560) with less involvement for other case types. Most laboratories reported that newly diagnosed primary pulmonary adenocarcinomas were triaged for molecular testing of epidermal growth factor receptor and anaplastic lymphoma kinase. CONCLUSIONS: The parameters examined in this 2013 survey provide a snapshot of current pulmonary cytopathology practice and may be used as benchmarks in the future.

Pipelle endometrial sampling in the evaluation of abnormal first trimester pregnancies.

OBJECTIVE: To evaluate the utility of pipelle endometrial sampling as a diagnostic tool in the evaluation of abnormal first trimester gestations. METHODS: Thirty-one women with abnormal first trimester pregnancies defined as gestations with abnormally rising or falling quantitative human chorionic gonadotropin (ß-hCG) levels and ultrasound findings consistent with a nonviable or ectopic pregnancy were prospectively evaluated. Endometrial pipelle sampling was performed on each patient in a standardized fashion immediately before curettage and evaluated as a fixed, permanent specimen to assess for the presence of either chorionic villi, trophoblastic or fetal tissue. RESULTS: The sensitivity, specificity, positive predictive value, and negative predictive value for endometrial biopsy were 70.1%, 100%, 100%, and 33.3%, respectively. For curettage, the sensitivity, specificity, positive predictive value, and negative predictive value were 88.9%, 100%, 100%, and 57.1%, respectively. CONCLUSION: Curettage's overall sensitivity is superior to endometrial biopsy in detecting the presence of intrauterine products of conception in early abnormal pregnancies. However, in some clinical situations where the diagnosis of ectopic pregnancy is in question, particularly if the ß-hCG is ≤ 2,000 mIU/mL, endometrial pipelle biopsy could be a useful tool in the evaluation algorithm.

Benign papillomas diagnosed on large-gauge vacuum-assisted core needle biopsy which span <1.5 cm do not need surgical excision.

The objective of our study is to determine if a carefully selected subset of benign breast papillomas (size ≤1.5 cm) can be safely followed by imaging surveillance instead of immediate surgical excision. Over a 6½-year period, 86 breast lesions were diagnosed as a benign papilloma (BP) utilizing an 11- or 8-gauge vacuum-assisted core needle biopsy (VACNB) device. In general, it was our intent to remove as much of the radiologically evident lesion as possible. These 86 lesions underwent ≥2 years of imaging surveillance, without surgical excision following initial detection. With ≥2 years of radiologic follow-up, none of the 86 BPs demonstrated imaging findings that necessitated repeat biopsy or surgical excision. Benign breast papillomas ≤1.5 cm that are biopsied using an 11- or 8-gauge VACNB device with intent to remove as much of the radiologically evident lesion as possible are safe to undergo serial imaging surveillance rather than immediate surgical excision.

Serial MR findings and comprehensive review of bilateral lupus mastitis with an additional case report.

Lupus Mastitis (LM) is a rare presentation of lupus panniculitis involving the breast. Because it often presents as a tender palpable mass, a workup for malignancy usually ensues. It is well documented that surgery may worsen the condition; therefore, it is important to consider LM in the differential of a palpable breast mass in patients with systemic lupus erythematosus (SLE). Currently, management of LM remains primarily medical. We discuss the multi-disciplinary work-up of LM, and further describe its appearance on serial Magnetic Resonance (MR) exams.

Bladder schwannoma -- a case presentation.

Bladder schwannomas are exceedingly rare, benign or malignant, nerve sheath tumors that are most often discovered in patients with a known diagnosis of Neurofibromatosis type 1 (NF1). A few sporadic case reports of bladder schwannoma have been published in urologic, obstetric/gynecologic, and pathologic journals. However, this is the first case report in the radiologic literature where computed tomography imaging and radiology-specific descriptions are discussed. Furthermore, the patient presented in this case is only the fifth published patient without NF1 to be diagnosed with a bladder schwannoma, to the best of our knowledge.

The treatment of radial scars in the modern era--surgical excision is not required.

The clinical significance of isolated radial scars (RS) diagnosed on core needle biopsy (CNB) remains unclear. By determining the pathologic concordance rate, we sought to define the indications for surgical excision for RS diagnosed on CNB. Between January 1994 and December 2007, 38 RS were diagnosed by CNB. Twenty-eight underwent surgical excision with 27 (96%) patients having further benign diagnoses. One patient, who was found to have invasive cancer on CNB, was also found to have malignancy on open biopsy. Fourteen lesions were diagnosed by 8-gauge, 13 lesions by 11-gauge, and one lesion by 14-gauge biopsy needles. Seven studies met inclusion criteria for analysis; 341 lesions with follow-on surgical biopsy were identified. Sixteen (5%) radial'scars were found to harbor malignancy and all were percutaneously biopsied with 14-gauge needles. With the inclusion of the current study, none of the isolated radial scars diagnosed by the larger 11- or 8-gauge biopsy needles resulted in upgraded lesions on follow-on surgical biopsy. Based on the current review, histologic radial scars are infrequently associated with occult malignancy and do not mandate surgical excision. Indications for excision include the mammographic diagnosis of RS and specimens associated with atypia that would otherwise require open biopsy.

Malignant priapism secondary to adenocarcinoma of the prostate.

The authors report a case of an older gentleman with a history of metastatic prostate cancer who presented to the emergency department following 3 weeks of progressively intermittent and then continuous priapism. After an initial clinical workup, an MRI was performed of the pelvis for further evaluation of the patient's condition which demonstrated metastatic lesions within his corpora cavernosa. The patient underwent follow-up core-needle biopsy with pathologically proven metastasis.

Sclerosing hemangioma of the lung.

We present a brief review of sclerosing hemangioma, an uncommon but histologically distinctive neoplasm of the lung. Based on immunohistochemical and molecular findings, sclerosing hemangioma is thought to be derived from incompletely differentiated respiratory epithelium. Sclerosing hemangiomas typically present as asymptomatic, peripheral, solitary, well-circumscribed lesions in women with a mean age at diagnosis in the fifth decade. Rare cases are reported to have regional lymph node metastases; however, metastases do not appear to affect long-term survival. Histologically, sclerosing hemangioma is characterized by a distinct constellation of findings including 2 epithelial cell types, surface cells and round cells, which form 4 architectural patterns, papillary, sclerotic, solid, and hemorrhagic. Sclerosing hemangioma of the lung is generally considered to be a benign lesion, and surgical excision is curative without the need for additional treatment.

Ewing's sarcoma family tumors mimicking primary central nervous system neoplasms.

Ewing's sarcoma family tumors (ESFTs) and embyronal tumors of the central nervous system are malignant primitive neuroectodermal tumors (PNETs) that can arise in the central nervous system, bones, or soft tissues. When ESFTs involve the central nervous system or nearby structures the diagnosis depends on cytogenetics and immunohistochemistry as these tumors can appear otherwise histologically identical to central PNETs. Correct diagnosis is essential as the treatment paradigms for both entities differ. We present two cases of isolated central nervous system presentations of ESFTs mimicking primary central nervous system neoplasms.

Bioprosthetic repair of complex duodenal injury in a porcine model.

BACKGROUND: Complex duodenal injury remains a challenging problem for the trauma surgeon. Although primary repair of small injuries is often possible, extensive damage requires complex enteric reconstruction and drainage procedures. We sought to determine the efficacy of a bioprosthetic repair for large duodenal wounds in a porcine model. METHODS: A 60% circumferential wall defect in the second portion of the duodenum was created in eight female Yorkshire swine (38 kg +/- 5 kg). After 30 minutes of peritoneal soilage, a bioprosthetic repair using 1.5 mm porcine acellular dermal matrix was performed. Animals were recovered and resumed a normal diet on day 3. Repeat abdominal exploration and anastomotic bursting pressure strength was performed at 1-, 2-, 3-, and 6-week intervals. Pathologic analysis of all specimens was performed. RESULTS: All animals tolerated a normal diet postoperatively, with progressive weight gain and normal bowel function. On re-exploration, no animal had evidence of duodenal stenosis, proximal dilation, or abscess formation. Pathologic analysis demonstrated progressive in-growth of native bowel tissue, with almost complete incorporation at 6 weeks. Mean bursting pressure (202 mm Hg +/- 60 mm Hg) occurred at native bowel, not patch repair site, in three of eight animals. CONCLUSION: Bioprosthetic repair of enteric wall defects, even in proximity to upper intestinal secretions, allows successful recovery of bowel function and injury repair without extensive anatomic reconstruction. This technique may provide a more conservative approach to the treatment of complex duodenal injuries after trauma.

Check Sample Abstracts.

The following abstracts are compiled from Check Sample exercises published in 2008. These peer-reviewed case studies assist laboratory professionals with continuing medical education and are developed in the areas of clinical chemistry, cytopathology, forensic pathology, hematology, microbiology, surgical pathology, and transfusion medicine. Abstracts for all exercises published in the program will appear annually in AJCP.

Atypical ductal hyperplasia: improved accuracy with the 11-gauge vacuum-assisted versus the 14-gauge core biopsy needle.

BACKGROUND: Percutaneous stereotactic core needle biopsy (CNB) has become the primary diagnostic modality for evaluating nonpalpable, mammographically detected breast lesions. Atypical ductal hyperplasia (ADH) uncovered by CNB confers a significant risk of harboring an occult malignancy in the excisional biopsy specimen; therefore, we sought to determine the benefits of upsizing biopsy needles from 14- to 11-gauge. METHODS: Patients with isolated ADH diagnosed by CNB were included for analysis in this retrospective review. Mammographic description, number of needle passes, pathology results, and follow-up data were analyzed and compared to our previously published institutional results with the 14-gauge needle. RESULTS: From June 1996 until July 2006, 4,579 CNBs were performed at our tertiary level medical facility. Seventy eight of 88 patients (89%) diagnosed with ADH on CNB with an 11-gauge vacuum-assisted needle underwent open surgical excision. Of these patients, nine (11%) were upgraded to ductal carcinoma in-situ (DCIS) while five (6%) had invasive cancer (IC), giving a total underestimation rate of 17%. These results differ from our previously published series of 14-gauge CNB which revealed an underestimation rate of 36%. Mean number of passes obtained at time of biopsy, mean age of patients, and characteristic radiographic abnormalities were similar for malignant and benign diagnoses. CONCLUSION: 11-gauge CNB technique reduces sampling error and improves accuracy, but does not eliminate the risk of missing an underlying malignancy. Surgical excision of ADH identified by CNB is required for definitive diagnosis.

Breast papillomas in the era of percutaneous needle biopsy.

BACKGROUND: The significance of breast papillomas detected on core needle biopsy (CNB) remains unclear. While those associated with malignancy or atypia are excised, no clear solution exists for benign papillomas. We sought to determine the indication for surgical excision, incidence of malignancy, significance, and natural history. METHODS: In this retrospective review, patients were divided into benign, atypical, or malignant cohorts based on initial results. While patients with malignant or atypical features were encouraged to undergo surgical excision, no standard recommendation was given for benign papillomas. Mammographic features, method of initial diagnosis, pathology results, and follow-up data were analyzed. RESULTS: Between January 1994 to December 2005, 5,257 CNBs were performed at our tertiary level medical center. 206 patients were diagnosed with 215 breast papillomas. 174 (81%) papillomas were benign, 26 (12%) were associated with atypia, and 15 (7%) were associated with malignancy. Two benign papillomas (1.1%) developed into cancer over an average of 53 months. Average follow-up of those patients not undergoing excision for benign papilloma was 41 months; we had 92 patients with greater than two year follow-up and 57 patients with greater than four year follow-up. Of patients with atypia or malignancy associated with papilloma, there was a 26% and 87% associated rate of malignancy, respectively. CONCLUSIONS: Benign breast papillomas diagnosed by CNB have a low risk of malignancy and do not need excision. However, they should be considered high risk lesions which require serial radiographic monitoring. Papillomas associated with atypia or malignancy should continue to be excised.