Interpretive Errors in Fine-Needle Aspiration of Thyroid: A 13-Year Institutional Experience in Lebanon.

INTRODUCTION: Fine-needle aspiration (FNA) is a worldwide established diagnostic tool for the assessment of patients with thyroid nodules. All thyroid FNA interpretive errors (IEs) were reviewed at the American University of Beirut Medical Center over a 13-year period, in order to identify and analyze them. MATERIALS AND METHODS: All FNAs and their corresponding pathology results are correlated yearly for quality assurance. Discrepant cases are segregated into sampling errors and IEs. All thyroid FNAs with IEs were collected from 2005 to 2017. FNA and pathology slides were reviewed by trained, board-certified cytopathologists, adhering to the latest Bethesda criteria. Reasons for erroneous diagnoses were studied. RESULTS: There was a total of 11 IEs out of 340 thyroid FNAs followed by surgical resection. Five benign follicular nodules (BFNs) were misinterpreted as suspicious for carcinoma. Focal nuclear atypia in cyst-lining or follicular cells and a monotonous population of macrophages misinterpreted as Hurthle cells (HCs) were the causes of IEs in this category. Four Hashimoto's thyroiditis (HT) cases were misinterpreted as suspicious for malignancy. Innate atypia of HCs and sampling misinterpretation were the causes of IEs in HT. One medullary and 1 follicular carcinoma were misinterpreted as suspicious for follicular neoplasm and BFN, respectively. Nine cases were better classified after review. CONCLUSION: Thyroid FNA IEs can be mitigated by meticulous screening and identification of all elements on FNA smears. Awareness of focal nuclear atypia in reactive cyst-lining and follicular cells in BFN, as well as HCs in HT, is highlighted. Adherence to The Bethesda System for Reporting Thyroid Cytopathology and consulting experienced cytopathologists significantly decrease IEs.

Randomized Cross-over Trial of Endobronchial Ultrasound Transbronchial Needle Aspiration With or Without Suction in Suspected Malignant Lymphadenopathy.

RATIONALE: The benefit from applying suction during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is unclear. BACKGROUND: The purpose of this study was to evaluate the impact of applying suction during EBUS-TBNA of lymph nodes (LN) on the diagnostic yield and specimen quality of EBUS-TBNA smears and cellblocks. METHODS: We conducted a randomized blinded cross-over trial comparing the diagnostic yield and quality of EBUS-TBNA samples obtained with suction (S+) and without suction (S-) from suspected malignant mediastinal LN. Each LN was aspirated 4 times in a randomly assigned alternating order: S+/S-/S+/S- or S-/S+/S-/S+, resulting in 2 matched S+/S- smears pairs and 1 matched S+/S- cellblocks pairs. Specimen were assessed by a blinded cytopathologist. The primary outcome was the diagnostic yield of EBUS-TBNA smears and cellblocks. Secondary analyses accounted for LN size (≤2 vs. >2 cm) and station (mediastinal vs. hilar). RESULTS: Of 234 EBUS-TBNA smears and 114 cellblocks were obtained from 59 LN. The concordance of S+ and S- cellblocks diagnostic yield was low (43.8%; 95% confidence interval: 30.7-57.6) with a significantly higher diagnostic yield among S+ compared with S- cellblocks (56.1% vs. 10.5%, respectively, P<0.001), regardless of LN station and size. However, S+ and S- smears were moderately concordant (66.7%; 95% confidence interval: 57.4-75.1) with no overall difference in their respective diagnostic yield. Numerically higher diagnostic yield among S+ smears in LN≤2 cm or hilar LN was not statistically significant. Results were similar for specimen adequacy, sensitivity and diagnosis of malignancy. CONCLUSION: Applying suction during EBUS-TBNA of suspected malignant LN enhanced the diagnostic yield of cellblocks regardless of mediastinal LN station or size, but not of smears.

Fibroblastic and myofibroblastic tumors of the head and neck: comprehensive imaging-based review with pathologic correlation.

Fibroblastic and myofibroblastic tumors of the head and neck are a heterogeneous group of disorders characterized by the proliferation of fibroblasts, myofibroblasts, or both. These tumors may be further subclassified on the basis of their behavior as benign, intermediate with malignant potential, or malignant. There are different types of fibroblastic and myofibroblastic tumors that can involve the head and neck including desmoid-type fibromatosis, solitary fibrous tumor, myofibroma/myofibromatosis, nodular fasciitis, nasopharyngeal angiofibroma, fibrosarcoma, dermatofibrosarcoma protuberans, fibromatosis coli, inflammatory myofibroblastic tumor, ossifying fibroma, fibrous histiocytoma, nodular fasciitis, fibromyxoma, hyaline fibromatosis and fibrous hamartoma. Although the imaging characteristics of fibroblastic and myofibroblastic tumors of the head and neck are nonspecific, imaging plays a pivotal role in the noninvasive diagnosis and characterization of these tumors, providing information about the constitution of tumors, their extension and invasion of adjacent structures. Correlation with the clinical history may help limit the differential diagnosis and radiologists should be familiar with the imaging appearance of these tumors to reach an accurate diagnosis.

Inconclusive or erroneous fine-needle aspirates of breast with adequate and representative material: a cytologic/histologic study.

Adequately cellular and representative fine-needle aspirates (FNAs) of breast have a high diagnostic accuracy. There is, however, a recognized category designated as "gray zone" where a definitive diagnosis cannot be reached. We reviewed our experience in this category to identify useful diagnostic parameters. Twenty-four such FNAs with surgical follow-up were retrieved from AUBMC files (2003-2009). Cytology slides were reviewed blindly. All cases were females, 29-73 years. There were three erroneous and 21 inconclusive diagnoses. The majority (15) was invasive adenocarcinomas: two cribriform, four tubular, one lobular, and eight not otherwise specified. The remaining cases were papillary and fibroepithelial tumors (three each), ductal carcinoma in situ, cribriform (two), and one adenomyoepithelioma (AME). Useful diagnostic features included: (1) Biphasic cell population with focal nuclear atypia and intranuclear and cytoplasmic vacuolar inclusions (AME). (2) Complex clusters of epithelial cells with cribriform architecture (cribriform carcinoma). (3) Rigid tubular epithelial structures with abrupt change in diameter, ending in pointed tips with abnormal branching (tubular carcinoma). (4) Cellular stromal fragments (fibroepithelial tumors). (5) Papillary fibrovascular cores, columnar cells, and three-dimensional papillary epithelial fragments (papillary tumors). Myoepithelial cells classically described in benign aspirates were not always a discriminatory factor. The "gray zone" in breast FNA is usually due to overlapping cytologic features of some benign and malignant lesions. Useful distinguishing cytologic features are described.

Follicular dendritic cell sarcoma of the head and neck expressing thyroid transcription factor-1: a case report with clinicopathologic and immunohistochemical literature review.

Follicular dendritic cell sarcoma (FDCS) is a rare neoplasm of follicular dendritic cells, most commonly affecting the lymph nodes and extranodal soft tissues of the head and neck, but also potentially arising in any visceral organ. FDCS with its diverse morphologies raises an occasionally challenging differential of primary and metastatic tumors with overlapping histologic and immunohistochemical features. When involving the head and neck, FDCS may be confused with squamous cell carcinoma, undifferentiated carcinoma, extracranial meningioma, and variants of papillary thyroid carcinoma. We describe here a case of FDCS showing nuclear grooves, intranuclear pseudoinclusions, diffuse epithelial membrane antigen and focal cytokeratin staining, and the first documented report of positivity for thyroid transcription factor-1. A discussion of the differential diagnosis and potential diagnostic pitfalls in FDCS brought forth by thyroid transcription factor-1 immunoreactivity and a full review of clinicopathologic and immunohistochemical features of head and neck FDCS are presented.

Indeterminate and erroneous fine-needle aspirates of breast with focus on the 'true gray zone': a review.

OBJECTIVE: To review our experience and the literature on inconclusive/erroneous fine-needle aspirates (FNAs) of breast with the focus on the 'true gray zone'. To describe the cytology, differential diagnosis, pitfalls and limitations of common and rare lesions. STUDY DESIGN: We conducted a literature search focusing on breast FNAs with statistical data of C3 and C4 categories including false-positive and false-negative cases. Similar data from 2003 to 2009 was obtained from our institution. RESULTS: C3 and C4 categories account for 3-17% of breast FNAs. Contributing factors are technical difficulties, inexperienced pathologists interpreting FNAs of breast and overlap of cytologic features of certain benign and malignant conditions; this last, 'true gray zone' accounts for 2% of cases. Fibroadenoma, proliferative breast lesions, gynecomastia, infiltrating and in situ low-grade adenocarcinomas and tubular, cribriform, lobular and mucinous carcinomas are the most common problematic lesions. Granular cell tumor, adenomyoepithelioma, pregnancy-related lesions, fat necrosis, inflammatory and radiation changes, adenoid cystic carcinoma, spindle-cell lesions and Phyllodes tumor are less common. CONCLUSION: Inconclusive/erroneous FNAs of breast due to the 'true gray zone' are rare. Most are due to the overlapping cytologic features of some benign and malignant conditions. Practical features that may help arrive at the correct diagnoses are elucidated.

The association of Hashimoto disease and Congo red negative amyloidosis.

Systemic amyloidosis which is characterized by extracellular deposition of monoclonal immunoglobulin light chains in various organs may be difficult to diagnose at an early stage, especially when the Congo red stain is negative. We describe herein a case of Congo red negative primary amyloidosis associated with Hashimoto thyroiditis. The patient presented with multiple organ involvement suggestive of amyloidosis including heart failure, renal failure, and macroglossia. Serum and urine immunofixation studies were positive for monoclonal chains. Even though a biopsy taken from the enlarged tongue of the patient was negative when stained with Congo red, electron microscopy showed ultrastructural features of amyloid deposition. In conclusion, we are reporting a rare case of primary amyloidosis with a negative Congo red stain associated with Hashimoto thyroiditis.

Bilateral lower eyelid margin erosion associated with lichen planus.

A 32-year-old woman presented with bilateral lower eyelid margin erosion and erythema of several years' duration. She reported no improvement with the use of topical corticosteroid therapy. A full-thickness excisional biopsy was performed, and the histopathology of the specimens was consistent with lichen planus.

Subacute thyroiditis: fine-needle aspiration cytology of 14 cases presenting with thyroid nodules.

Subacute thyroiditis (SAT) is usually diagnosed clinically without the need for fine-needle aspiration. The cytologic literature on this condition is therefore rare. We report on 14 cases of SAT presenting with thyroid nodules. The majority of patients were women with a mean age of 46 yr. All had pain/tenderness in the thyroid area accompanied by fever or an elevated ESR. The salient cytologic features included cellular smears; multinucleated giant cells in 100% of cases, some ingesting colloid or neutrophils; fibrous fragments with enmeshed inflammatory cells were a constant feature; follicular cells were scant to absent in most cases. Granulomas were rare. Colloid, when present was thick, with central cracks and frayed edges. One case was suspicious for malignancy. We conclude that the cytologic features of SAT are predictable, particularly, in the appropriate clinical setting. FNA is also helpful in ruling out concomitant neoplastic conditions.

Atorvastatin-induced severe gastric ulceration: a case report.

A 41-year-old man presented with severe gastric ulceration 3 mo after beginning treatment with atorvastatin 20 mg once daily for hypercholesterolemia. The patient was not taking any ulcerogenic drugs and had no evidence of Helicobacter pylori infection. Proton pump inhibitor therapy was initiated and atorvastatin was replaced by simvastatin with complete resolution of gastrointestinal symptoms. To our knowledge, this is the first report of atorvastatin-induced gastric ulceration, which should be looked for in patients who develop abdominal pain while on this drug.

Clinical presentation and treatment outcome of children with Burkitt lymphoma in Lebanon: a single institution's experience.

The authors reviewed the medical records of 42 children younger than 13 years of age diagnosed with Burkitt lymphoma at the American University of Beirut Medical Center between 1983 and 1993. The male:female ratio was 3.9. The abdomen was the most common site of disease (86%). Jaw, central nervous system, and bone marrow involvement occurred in 16.6%, 16.6%, and 9.5%, respectively. The mean LDH level was 447 U/L. The mean age at diagnosis was 6.9 years. Thirty-nine patients received a variation of the COMP protocol. The total duration of treatment ranged from 6 to 18 months. At a median follow-up of 5 years the event-free survival was 100% for children with stages I and II disease, 77.4% (+/- 2 SE) for stage III, and 0% for stage IV. Failures in stage III patients were due to tumor lysis (3/24) and progressive disease (2/24). Aggressive therapy with high doses of methotrexate and anthracyclines may not be necessary for the treatment of children with extensive abdominal disease (stage III) in Lebanon. If confirmed in a larger series of patients, this study could have a major impact on the treatment of Burkitt lymphoma in Lebanon and other countries with limited resources.

CT findings of omental torsion and infarction: case report and review of the literature.

A 37-year-old woman presented with progressive diffuse abdominal pain. Computed tomography (CT) showed diffuse streaking of the greater omentum with a mass of fat density located anteriorly just below the umbilicus, showing a whirling pattern of concentric streaks. Surgery and pathology revealed torsion and infarction of the greater omentum. Because of its rarity and nonspecific clinical features, the diagnosis is seldom made preoperatively. We describe a patient with characteristic CT findings of omental torsion. Preoperative diagnosis is important since conservative management has been suggested.

Juvenile ossifying fibroma: CT and MR findings.

We describe the CT findings in four patients and the MR imaging in one patient with juvenile ossifying fibroma. Three lesions involved the maxillary sinus and extended to the surrounding structures; one lesion was confined to the maxillary bone. CT scan revealed well-defined, expansile lesions with variable amount of calcifications. On MRI one lesion had intermediate signal intensity with significant contrast enhancement.