Parathyroid adenoma associated with a branchial cleft cyst.

An unusual case of parathyroid adenoma is presented. This adenoma presented as a rapidly expanding neck mass in a normocalcemic patient. It was located far laterally in the neck, in association with the internal jugular vein and with a branchial cleft cyst. This case provides an unusual presentation of parathyroid adenoma. It also provides an elegant demonstration of developmental anatomy as well as the mechanism of parathyroid ectopia in the lateral aspect of the neck.

Paranuclear blue inclusions in small cell undifferentiated carcinoma: a diagnostically useful finding demonstrated in fine-needle aspiration biopsy smears.

In a study of bone marrow aspiration smears, Wittchow et al. (Mod Pathol 1992;5:555-558) described a highly characteristic finding, paranuclear blue inclusions (PBIs), found almost exclusively in cases of metastatic small cell undifferentiated carcinoma (SCUC). PBIs are 1-4 microns, light blue, cytoplasmic inclusions best visualized with Romanowsky-type stains. These inclusions are most easily found indenting the nuclei within clusters of closely opposed tumor cells. In the current study air-dried fine-needle aspiration biopsy (FNAB) smears from 146 primary and metastatic small cell and non-small cell adult and childhood malignancies were reviewed. PBIs were found in 28/32 (88%) of SCUC but were observed in only 4/44 (9%) non-small cell carcinomas, 2/21 (9.5%) lymphomas, 1/8 (12.5%) melanomas, 0/14 sarcomas, and 6/27 (22%) small round cell neoplasms. These results suggest that the presence of PBIs in air-dried FNAB smears of adult neoplasms, while not pathognamonic of SCUC, are a diagnostically useful finding. PBIs may be seen in a variety of different childhood small round cell neoplasms which limits their utility in this setting. The recognition of PBIs is most important to the cytologist who may not have access to ancillary studies, such as immunohistochemistry and electron microscopy.

Fine-needle aspiration biopsy of subcutaneous fat necrosis of the newborn.

This report provides the first description of the fine-needle aspiration biopsy findings in a case of subcutaneous fat necrosis of the newborn. While initial interpretation of the aspirate smears was suspicious for a neoplastic process, subsequent incisional biopsy confirmed the benign nature of the lesion. Review of the cytologic material revealed rare, negatively stained, needle-shaped crystals within histiocytes and multinucleate giant cells. In the appropriate clinical setting, and given a mixture of lymphocytes, histiocytes, and multinucleate giant cells in the aspirate smears, we believe the finding of negatively stained needle-shaped crystals can strongly suggest the diagnosis of subcutaneous fat necrosis of the newborn.

Immunohistochemical distinction of classic and chondroid chordomas.

Chondroid chordomas are cartilage-rich neoplasms, most often located in the spheno-occipital region, that have a better prognosis than classic chordomas. The immunohistochemical features of 19 classic and chondroid chordomas were studied retrospectively using avidin-biotin-complex (ABC) immunoperoxidase histochemistry on formalin-fixed, paraffin-embedded tissue. Of the 19 tumors, all located in the spheno-occipital region, 5 exhibited predominantly chondroid morphologic features. The 14 classic chordomas showed the following pattern of antigen expression (percent of tumors positive): epithelial membrane antigen (EMA) 100%, AE 1/3 (a "cocktail" of monoclonal antibodies directed against low and high molecular weight epidermal cytokeratins) 100%, DP keratin (DPK) 100%, vimentin 100%, S100 86%, neuron specific enolase (NSE) 100%, carcinoembryonic antigen (CEA) 57%, and HMB-45 (an anti-melanoma-associated antibody) 57%. The five chondroid chordomas exhibited the following pattern: EMA 0%, AE 1/3 0%, DPK 0%, vimentin 100%, S100 100%, NSE 100%, CEA 0%, and HMB-45 0%. The focal, weak HMB-45 positivity (performed on the index case because of a clinical concern of metastatic melanoma) seen in 57% of the classic chordomas is a previously unreported finding. This finding suggests either that classic chordomas are capable of HMB-45 expression or that this antibody has broader reactivity than previously recognized. The lack of cytokeratin, EMA, and CEA expression by the chondroid chordomas is similar to chondrosarcomas as reported in the literature and dissimilar to the classic chordoma group. These immunohistochemical findings suggest that chondroid chordomas may more validly be classified as low grade chondrosarcomas.

Insular carcinoma: a distinct thyroid carcinoma with associated iodine-131 localization.

Insular carcinoma, once considered a poorly-differentiated thyroid cancer, has been reclassified as a distinct thyroid neoplasm. Since this neoplasm is composed of follicular epithelial cells, it may concentrate radioiodide (131I) making postoperative 131I imaging for detection of metastases and radiotherapy possible. A 20-yr review of 35 cases diagnosed as anaplastic or undifferentiated thyroid carcinoma at this medical center revealed five patients with insular carcinoma. Four patients showed postoperative 131I localization and received therapeutic doses of 131I. Three of the four showed extrathyroidal 131I localization in neoplastic lesions. In one patient, the resolution of metastatic lesions by magnetic resonance and 131I imaging suggests that 131I may have an important therapeutic role in this aggressive neoplasm.

Pulmonary-renal syndrome with "triad" involvement due to small vessel vasculitis.

We describe the clinical course and morphologic findings of a 22-year-old woman presenting with a systemic disease that included nasal ulceration, hemoptysis and rapidly progressive renal failure. Biopsies of nasal septum and lung revealed small vessel leukocytoclastic angiitis while renal biopsy showed a diffuse crescentic glomerulonephritis. Immunosuppressive therapy resulted in remission of clinical symptoms and resolution of glomerulonephritis as documented in a followup biopsy. Although her clinical presentation with triad organ involvement strongly suggested Wegener's granulomatosis, this case illustrates that other varieties of vasculitis may mimic Wegener's granulomatosis.

Cytologic findings in posttransplant lymphoproliferative disease.

Transplant patients are at an increased risk of developing lymphoproliferative disorders (LPDs). To examine the role of cytology in diagnosing LPDs, the cytologic reports on all transplant patients seen at the University of Iowa from January 1983 to July 1988 were reviewed. Thirteen of 649 transplant patients developed LPD; 10 of those 13 patients had a total of 25 cytologic specimens obtained within two months of the diagnosis of LPD available for review. Ten specimens (four cerebrospinal fluids [CSFs], four effusions, one respiratory specimen and one liver aspirate) from six patients were positive for LPD. Immunophenotypic or immunogenotypic studies on cytologic specimens from four patients showed a clonal B-cell process. The cytologic features ranged from those of a plasmacytoid LPD to those of an immunoblastic or large-cell lymphoma. An additional seven specimens (five CSFs, one effusion and one liver aspirate) from four patients were suspicious for LPD, exhibiting rare atypical cells or cells with plasmacytoid features. Ten patients died with LPD within 12 months; three are alive. Cytologic specimens, especially body fluids, are frequently positive in LPD and may be useful diagnostically. Since the differential diagnosis includes reactive lymphocytosis, confirmatory immunophenotypic or immunogenotypic studies are recommended.

Nuchal cystic hygroma associated with massive lymphangiomatosis of the upper extremity and myocardium in a stillborn fetus: a case report.

Nuchal cystic hygromas may be encountered in stillborn fetuses as part of a spectrum of a more generalized abnormality of the lymphatic system. These lymphatic system abnormalities may be accompanied by various visceral anomalies, especially in Ullrich-Turner Syndrome (UTS) (45,X0) but also in non-45,XO fetuses. We present unique autopsy findings in the case of a stillborn female fetus with a nuchal cystic hygroma associated with massive lymphangiomatosis of the upper extremity as well as myocardium. While previous descriptions of abnormal cardiac lymphatics associated with nuchal cystic hygroma have focused on dilated lymphatics surrounding the root of the aorta and pulmonary artery, the present case extends the spectrum of possible findings to include subtotal replacement of the ventricular myocardium by dilated lymphatics.

Recurrent multifocal adult rhabdomyoma diagnosed by fine-needle aspiration cytology: report of a case and review of the literature.

The fine needle aspiration (FNA) cytology of a recurrent multifocal extracardiac adult rhabdomyoma is described, and the literature is reviewed. The patient presented with dysphagia and bilateral palpable neck masses 21 yr after resection of a rhabdomyoma of the tongue. The clinical differential diagnoses included ptotic submandibular glands and lymphadenopathy. The aspiration smears and cytospin preparations contained large polygonal cells with abundant granular cytoplasm with indistinct borders and uniform, peripherally located nuclei. Cross-striations were identified within the cytoplasm of some cells on Papanicolaou and modified Wright-Giemsa stains. This case represents only the fourth description of the cytology of this entity and the first reported case of a recurrence diagnosed by FNA. The characteristic cytomorphologic features enabled a definitive diagnosis to be made 21 yr after the original resection, sparing a poor-risk patient a debilitating surgical procedure for a benign, slow-growing neoplasm.

Pulmonary-renal syndrome: clinical similarity amidst etiologic diversity.

The medical records and morphologic materials (59 biopsies, 7 autopsies) of 21 patients presenting with a pulmonary-renal syndrome (PRS) were reviewed. A variety of disorders (Goodpasture's syndrome, 3; vasculitis, 7; idiopathic crescentic glomerulonephritis, 7; spurious PRS, 4) may have PRS presentation. Seventeen patients had extrarenal vasculitis and/or crescentic glomerulonephritis and were treated with immunosuppression. Seven patients died, six from complications related to infections and cardiovascular disease but only one from his original disease. Four other patients ("spurious" PRS) who did not have crescents or extrarenal vasculitis did well with supportive therapy alone. We conclude that a pulmonary-renal syndrome is a common manifestation of diverse disorders which differ in their prognosis and therapy. Since clinical parameters alone are too insensitive to resolve the etiologic possibilities, multiple biopsies and serologies tests are required for a reliable diagnosis.

Primary adenocarcinoma of the duodenal bulb: radiographic and pathologic findings in two cases.

We reviewed the radiographic and pathologic findings in 2 patients with primary adenocarcinoma of the duodenal bulb. Barium studies provided important information, characterizing the nature and extent of the lesion, as well as complete evaluation of the descending and horizontal segments of the duodenum before surgical therapy. Early endoscopy is recommended for nonhealing duodenal ulcers, especially if suggestive malignant changes are present.