Biliary brushing cytology.

Biliary tract brush specimens are fast becoming the method of choice in the evaluation of patients who present with biliary tract strictures. Although the specificity is high, sensitivity rates for the detection of malignancy are generally low on cytological sampling. New liquid-based preparations and ancillary tests have emerged with the intent of addressing this issue. This review focuses on the current schemata used in the diagnosis of biliary tract lesions and the current available modalities which aid in the diagnosis of cholangiocarcinoma.

Immature teratoma of the ovary on fluid cytology.

A case of an immature teratoma of the ovary in the peritoneal fluid of a 10-yr-old girl who presented with a pelvic mass is presented and discussed. The ThinPrep preparation showed a few tight clusters of small tumor cells with a high nuclear/cytoplasmic ratio, round to oval nuclei with evenly distributed chromatin and one to two small distinct nucleoli, and scanty cytoplasm. The presence of immunohistochemical-confirmed glial tissue on the cell block preparation confirmed the diagnosis of an immature ovarian teratoma. The differential diagnosis of fluid cytology is discussed.

Cytologic diagnosis of peripheral T-cell lymphoma manifesting as ascites. A case report.

BACKGROUND: Patients with malignant lymphoma seldom present with effusions without a known history of malignancy. Because of this, initial diagnosis of malignant lymphoma by effusion cytology is uncommon, with few reported cases. CASE: A 75-year-old male presented with fatigue, decreased appetite and progressively increasing abdominal girth over five weeks. Cytologic examination of ascitic fluid obtained by paracentesis revealed non-Hodgkin's lymphoma with a T-cell phenotype, confirmed by immunophenotypic and molecular studies. Approximately one week later, histologic examination of liver and bone marrow revealed involvement by lymphoma, demonstrating immunophenotypic and molecular profiles identical to those obtained from neoplastic lymphocytes recovered from the ascites fluid. CONCLUSION: This case demonstrates a rare presentation of peripheral T-cell lymphoma, clinically manifesting as ascites. In cases such as ours, where the effusion consists predominantly of small to intermediate-sized lymphocytes, distinguishing lymphoma from reactive lymphocytosis may be difficult. This case not only demonstrates the value of effusion cytology for lymphoma diagnosis but also illustrates how the use of various immunophenotypic and molecular techniques may assist the pathologist in properly diagnosing these difficult cases.

Cytomorphology of small-cell (neuroendocrine) carcinoma on ThinPrep cytology as compared to conventional smears.

Small-cell (neuroendocrine) carcinoma of the female genital tract is an uncommon, aggressive neoplasm that occurs most commonly in the cervix and rarely in the vagina. Although the cytologic findings have been reported on conventional smears, the cytologic diagnosis of primary vaginal small-cell carcinoma on ThinPrep material has not been previously reported. We present a case of a 46-yr-old woman who underwent cervical/vaginal biopsies as a result of abnormal cells seen on the ThinPrep Pap Test. Small to medium-sized cells with scant cytoplasm were present singly and in loose, cohesive clusters. Nuclear molding was noted in a few cellular groups. The differential diagnosis included a high-grade squamous intraepithelial lesion, small-cell (neuroendocrine) carcinoma, endometrial adenocarcinoma, and lymphoma. Subsequent tissue biopsies with immunohistochemical staining confirmed a diagnosis of small-cell carcinoma of the vagina. The cytologic features of small-cell (neuroendocrine) carcinoma on slides prepared by the ThinPrep Pap Test are discussed and compared to those on conventional cervicovaginal smears.

Fine-needle aspiration of extranodal and extramedullary hematopoietic malignancies.

There is relatively little information concerning the use of fine-needle aspiration (FNA) to diagnose extranodal and extramedullary hematopoietic malignancies. Seventy-one such cases diagnosed by FNA form the basis of this study. Seventy-one cases of FNAs performed between 1988 and 1998 on extranodal and extramedullary hematopoietic malignancies were reviewed in order to evaluate the usefulness of this technique in diagnosing these entities as well as to assess patterns of relapse. There were 45 male and 26 female patients ranging in age from 29-86 years (mean, 68 years). Sixty-six patients had a previous history of a hematopoietic malignancy. Aspirates from 65 of these patients were consistent with the patient's known primary. One aspirate of a paravertebral mass from a multiple myeloma patient showed extramedullary hematopoiesis. The remaining five aspirates were cases of multiple myeloma that first presented as soft tissue masses. The most common malignancies were lymphoma: 52 cases (73%), 48 large cell lymphomas, four mixed small and large cell lymphoma; followed by multiple myeloma: 12 cases (17%); leukemia: four cases (5.4%); Hodgkin disease: two cases (2.8%); and one case of extramedullary hematopoiesis. The aspirate sites were soft tissue: 23 cases (32%); bone: 17 cases (24%); kidney: 14 cases (20%); liver: 11 cases (15%); lung: three cases (4%); adrenal: two cases (3%); and eye: one case. The interval between primary diagnosis and FNA was 1-36 months (mean, 13 months). In conclusion, 98% of the aspirates were neoplastic in patients with a known history of hematopoietic malignancies. The most common site of involvement was soft tissue in 23 (32%) cases. In five patients with multiple myeloma, the FNA diagnosis prompted a work-up to find the primary site of involvement. FNA is a useful technique in assessing extranodal and extramedullary hematopoietic malignancies.

Fine-needle aspiration biopsy of the liver: a multicenter study of 602 radiologically guided FNA.

With improved radiologic techniques fine-needle aspiration (FNA) is becoming a rapid, effective diagnostic method in evaluating a wide range of liver masses. Review of six hundred two radiologically guided liver aspirates performed over a ten-year period forms the basis of this report.

Fine-needle aspiration of the thyroid: rate and causes of cytohistopathologic discordance.

Fine-needle aspiration (FNA) of the thyroid gland is a widely utilized, sensitive, specific, and cost-effective method for the evaluation of thyroid nodules. The purpose of this study was to evaluate the accuracy of thyroid FNA and causes of cytohistological discordance in our institution. Six hundred twenty-five thyroid FNAs obtained from 503 females (mean age, 54) and 122 males (mean age, 51) in whom histopathologic follow-up material was available for review, were analyzed. FNAs were classified as: nondiagnostic, negative, intermediate, and positive for malignancy, and the histopathologic material was categorized as benign or malignant. The review revealed 93% sensitivity and 96% specificity for the FNA diagnoses. The FNA results were diagnostic in 87%, indeterminate in 6%, and nondiagnostic in 7% of the cases. Cytohistologic correlation was achieved in 88% of the cases. The false-negative rate was 4% and the false-positive rate was 8%. The most common pitfalls for false-negative diagnoses consisted of suboptimal material and underdiagnosis of papillary carcinoma due to cystic degeneration. The most common pitfall for false-positive cases was overdiagnosis of follicular neoplasms. Our study confirmed that FNA of thyroid nodules can be performed with high sensitivity and specificity by experienced clinicians or pathologists. The application of strict specimen adequacy rules for FNA interpretation is likely to decrease the rate of false-negative and false-positive diagnoses.

Detection of endometrial adenocarcinoma with the ThinPrep Pap test.

The ThinPrep Pap Test (Cytyc Corp., Boxborough, MA) was introduced in the Loyola University Medical Center (LUMC) Cytopathology Laboratory in March 1997. This study presents a 26-month retrospective review of the cervicovaginal specimens on all patients who had a cytologic diagnosis of adenocarcinoma either by conventional (CS) or ThinPrep (TP) methods. From March 1997 through May 1999, 16,139 conventional smears and 29,589 TP Pap tests were sent to the LUMC cytopathology laboratory. The three diagnostic glandular categories included: atypical glandular cells of undetermined significance (AGUS); suspicious for adenocarcinoma, endometrial adenocarcinoma, and adenocarcinoma; not otherwise specified (nos). Cytohistologic correlation was performed on all available cases. Since endometrial adenocarcinoma occurs most frequently in peri- and postmenopausal patients, the percentage of patients over the age of 50 was determined for each method; 4,669 (29%) of the women receiving a CS were age 50 or over and 6,839 (23%) of the women who received the TP Pap test were in this age group. Sixteen endometrial lesions were identified on cytology, one (adenocarcinoma) with the CS method and 15 (six AGUS; suspicious for adenocarcinoma, four endometrial adenocarcinomas, and five adenocarcinomas; nos) with the TP method. The one CS case had biopsy confirmation. Fourteen of the 15 TP cases (93%) were confirmed by biopsy; one (7%) case had no follow-up. The TP Pap test yielded a higher percentage of endometrial adenocarcinomas (0.05%) as compared to CS (0.01%). Traditionally, CS has not been a method for the early detection of endometrial glandular lesions. However, of the patients diagnosed as having an endometrial adenocarcinoma in this study, the TP Pap test contributed to an increase in the detection of these lesions as compared to CS. The age group for the two methods was comparable.

Evaluation of cellular residue in the ThinPrep PreservCyt vial.

The ThinPrep Pap Testtrade mark is a fluid-based method used for the collection and preparation of cervicovaginal samples. The collection device(s) is/are rinsed in Cytyc's ThinPrep PreservCyt medium and a thin-layer slide is prepared using the ThinPrep 2000 automated processor. The purpose of this study was to determine the detection rates for cervical lesions utilizing an additional ThinPrep slide. Fifty-four cervical samples processed by the ThinPrep method were reviewed. An additional thin-layer slide was obtained from the cellular residue for each case utilizing a new filter. Case selection criteria included cases with a few equivocal cells, a few diagnostic cells, or several low-grade dysplastic cells seen on the original ThinPrep slide. The original slides and repeat slides were reviewed by two cytopathologists and two cytopathology fellows. Fifty-four patients were included in the study, mean age 35 years (range: 16-76). The original diagnoses included: 17 negative cases, 22 atypical squamous cells of undetermined significance (ASCUS), 10 low-grade squamous intraepithelial lesions (LGSILs), four high-grade squamous intraepithelial lesions (HGSILs), and one case of atypical glandular cells of undetermined significance (AGUS). On the repeat slides the diagnosis remained the same in 42 (77.8%) cases, diagnostic cells were not present in 10 (18.5%) cases, fungal elements consistent with candida were detected on the repeat smear in one case (1.8%), and higher grade dysplastic cells were found in two cases (3.7%). Our study showed that the ThinPrep method provides a representative, diagnostic sample on the slide. Repeat processing adds little to the overall diagnosis.

Specimen adequacy and the ThinPrep Pap Test: the endocervical component.

The ThinPrep Pap Test (Cyryc Corp., Boxborough, MA) has proven to be effective in decreasing the number of cervical specimens limited for interpretation by blood/inflammatory exudate as compared to conventional smears. However, its effectiveness in decreasing the number of preparations which lack an endocervical component is less well-established. The purpose of this 1-yr study (January 1998-December 1998) was to determine if the collecting instruments used by physicians played a role in the lack of an endocervical component on ThinPrep slides. On implementation of the ThinPrep Pap Test for cervical cytology, the broom-type sampling device (Papette, Wallach Surgical Devices, Inc., Millford, CT) was the FDA-approved collecting instrument. Subsequently the combined plastic spatula/Zelsmyr Cytobrush (Medscand, Inc., Hollywood, FL) were approved. A survey was sent to 102 physicians in seven primarY care sites and two private obstetrics-gynecology practices affiliated with the Loyola University Health Care System. One site used the broom only, one site used the spatula/cytobrush, five sites used the broom/cytobrush, and in two sites, two different sets of collecting instruments were utilized. Of the 10,241 ThinPrep samples, 620 (6%) were obtained with the broom only, 432 (4.3%) with the spatula/cytobrush, and 9,189 (89.7%) with the broom/cytobrush. An endocervical component was absent in 24% (range, 13.7-25%) of the cervical samples collected with the broom only, 10% (range, 8.4-12.5%) with the spatula/cytobrush, and 13% (range, 6.2-18.8%) with the broom/ cytobrush. The spatula/cytobrush and the broom/cytobrush showed statistical significance (P < 0.001) over the broom alone in the collection of an endocervical component. The results of this study indicate that the collecting instruments used by the physician(s) played a role in the adequacy (endocervical component) of the specimen processed by the ThinPrep method. Diagn. Cyto

Fine-needle aspiration of scalp lesions.

A variety of inflammatory and neoplastic scalp lesions are encountered in surgical pathology. However, the literature on fine-needle aspirations (FNAs) of the scalp is exceedingly rare. We report on a series of 70 FNAs involving cutaneous and subcutaneous lesions on the scalp. A total of 70 fine-needle aspirations of cutaneous and subcutaneous scalp lesions was reviewed to identify patterns of metastasis to the scalp and to demonstrate the effectiveness of FNA in diagnosing these lesions. There were 42 male and 28 female patients, ranging in age from 29-91 yr (mean, approximately 61 yr). Sixty-one patients had a previous history of malignancy. Of these aspirates, 59 were neoplastic, consistent with the patient's known primary. One case was an abscess, and the remaining case was unsatisfactorvy for cytologic evaluation. Follow-up biopsy revealed granulomatous inflammation. The most common primary tumor to metastasize to the scalp was lung carcinoma, which was seen in 18 cases, followed by hematopoietic malignancies in 14 cases. Melanoma was identified in 6 cases, head and neck tumors in 5 cases, renal malignancies in 4 cases, gastrointestinal tumors in 3 cases, sarcoma in 3 cases, breast and prostate malignancy in 2 cases each, and an olfactory neuroblastoma and meningioma in 1 case each. The remaining 9 aspirates were from patients who did not have a previous history of malignancy. These included 6 benign aspirates consisting of 3 epidermal inclusion cysts, 2 lipomas, and 1 neurofibroma. Two aspirates were malignant and included 1 primary squamous-cell carcinoma and 1 metastatic adenocarcinoma of unknown origin. The remaining case was unsatisfactory for cytologic evaluation. Follow-up biopsy of this lesion showed noncaseating granulomas. Of the aspirates from patients with a previous history of malignancy, 97% were neoplastic. Lung carcinoma and hematopoietic malignancies were the most common neoplasms that metastasized to the scalp. Since the scalp is a common site for metastasis, awareness of this fact is useful to both oncologists and dermatologists. It must be understood that FNA can provide a rapid and accurate diagnosis in the evaluation of scalp masses.

Role of fine-needle aspiration in the clinical management of solid organ transplant recipients: a review.

BACKGROUND: We evaluated the clinical course of the solid-organ transplant population at our institutions to determine the role of fine-needle aspiration (FNA) in the clinical management of this subgroup of patients. METHODS: 1196 allograft recipients (522 liver, 288 cardiac, 250 renal, 131 lung, 5 heart and lung) were reviewed. A total of 62 (5.2%) (32 liver, 23 heart, 6 lung, and 1 renal) transplant patients underwent an FNA procedure. Thirty-seven males and 25 females were included, ranging in age from 18 to 71 years (mean 50 years). RESULTS: Of the 62 fine-needle aspirates, 29 (47%) were neoplastic. The most common malignancies aspirated were malignant solid tumors (15 cases)-including 8 epithelial malignancies, 5 hepatocellular carcinomas, and 2 mesenchymal neoplasms-followed by posttransplant lymphoproliferative disorders (14 cases). Thirteen (21%) aspirates were inflammatory. The remaining 20 (32%) cases were benign aspirates from various sites (9 liver, 3 breast, 2 thyroid, 2 soft tissue, 2 lung, and 2 vertebral body). Surgical and/or autopsy material was available in 34 cases (55%). There was agreement between the tissue diagnosis and FNA material in 33 cases (97%). One case (3%) was a false negative. No false-positive cases were recorded. CONCLUSIONS: This study showed that over 50% of the aspirates were benign, justifying a conservative approach in the clinical management of these patients. Histologic correlation was available in 54% of the cases with an overall specificity of 100% and a sensitivity of 97%. We conclude that FNA is a highly sensitive and specific technique in the evaluation of lesions occurring in posttransplant patients. Cancer (Cancer Cytopathol)

Metastatic melanoma of the vulva identified by peritoneal fluid cytology.

Malignant melanoma of the vulva is an uncommon disease, with a significant portion of cases demonstrating metastasis to inguinal lymph nodes with potential distal spread. Identification of such metastases often requires fine-needle aspiration or biopsy. The cytologic diagnosis of metastatic vulvar melanoma from peritoneal effusions has not been previously described. We present the case of a 54-yr-old woman who underwent en bloc radical vulvectomy with bilateral inguinal lymphadenectomy for melanoma of the right labium minora. No evidence of metastatic disease was identified, and all surgical margins were free of tumor. Despite chemotherapy, the patient returned approximately 2 yr later with abdominal pain and distention. Computed tomography revealed marked ascites and three hepatic lesions. Cytologic examination of the ascites revealed recurrent, metastatic melanoma. Although very rare, metastatic melanoma of the vulva may present as a malignant effusion. In such an event, the diagnosis may be rendered by exfoliative cytology.

Use of the Thin Prep Pap Test in clinical practice.

The Thin Prep Pap Test (Cytyc Corp., Boxborough, MA) received approval by the Food and Drug Administration in May 1996 as an alternative to the traditional conventional smear. The present direct-to-vial study assessed the utility of thin-layer technology for cervicovaginal screening in clinical practice. From May 1997-February 1998 (10 mo), 15,006 cervical smears were processed and evaluated; of these, 5,423 (36.1%) were conventional smears (CS) and 9,583 (63.9%) were Thin Prep slides (TP). Both methods were analyzed to compare specimen adequacy and detection rates of cervical lesions. The TP method reduced the "satisfactory but limited by" rate by 97% and the unsatisfactory rate by 63%. For low-grade squamous intraepithelial lesions (LSILs), TP slides yielded 3.6% (348/9,583) as compared to 0.98% (53/5,423) for CS, an increase of 267%. The TP method detected a threefold increase in the number of high-grade squamous intraepithelial lesions (HSILs) of 1.0% (100/9,583), as compared to 0.3% (17/5,425) for the CS group. The atypical squamous cells of undetermined significance/squamous intraepithelial lesion (ASCUS SIL) ratio was reduced by 54% in the TP group. In routine usage in our laboratory, the Thin Prep Pap Test yielded a significant increase in the detection of LSILs and HSILs as compared to conventional smears. Specimen adequacy was significantly improved.

Lichen sclerosus in pregnancy: presentation of two cases.

Numerous skin diseases occurring in the pregnant patient have been reported. Some of these diseases are unique to pregnancy and some, including vulvar varicosities, vulvar edema, postpartum labial adhesions, and hematomas, are a result of physiological changes of pregnancy or the birth process. In addition, a variety of viral and bacterial infectious diseases of the vulva may occur during pregnancy. Vulvar neoplasms may also be found in pregnancy. In two patients, ages 27 and 31, lichen sclerosus first was diagnosed during their initial prenatal visits. Only one of the patients was symptomatic. The symptomatic patient used topical steroids for relief of vulvar itching. Two patients with lichen sclerosus of the vulva in pregnancy are reported, with emphasis on the diagnosis and treatment of this condition.