Comparison of fine-needle aspiration biopsy, Doppler ultrasound, and radionuclide scintigraphy in the diagnosis of acute allograft dysfunction in renal transplant recipients: sensitivity, specificity, and cost analysis.

150 episodes of allograft dysfunction in 128 renal transplant recipients, 77 due to acute rejection, 32 secondary to acute-on-chronic rejection, 33 due to either prerenal factors, acute tubular necrosis, or ciclosporin A nephrotoxicity, and 8 secondary to multiple causes, were evaluated by fine-needle aspiration biopsy (FNAB), Doppler ultrasound (DUS), and radionuclide scintigraphy (RS), each performed within a 24-hour period and prior to any specific therapeutic intervention. Tests were interpreted by appropriate specialists in a large transplant center without access to clinical information. The final diagnosis was based primarily upon response to therapeutic maneuvers with histological (core biopsy) confirmation in 123 episodes. RS was the most sensitive (70%) test for the diagnosis of acute rejection during the early posttransplant period, exceeding both FNAB (52%) and DUS (43%). The predictive accuracy of either FNAB, DUS, RS, or core biopsy in the detection of a steroid-responsive component to acute rejection when superimposed upon chronic rejection was low at approximately 50%. When the underlying cause of renal dysfunction was either prerenal, acute tubular necrosis, or ciclosporin A nephrotoxicity, FNAB, DUS, and RS each gave an erroneous diagnosis of acute rejection in about 50% of the episodes. Cost analysis revealed that core biopsy was the most expensive test, but only 9% more than RS, with FNAB the least costly. In conclusion, the lack of ideal sensitivity and specificity combined with the expense of present-day FNAB, DUS, RS, and core biopsy in the diagnosis of a therapeutically reversible component to acute-on-chronic rejection and of FNAB, DUS, and RS in the diagnosis of acute rejection during the early posttransplant period should prompt research into ways to improve their diagnostic yield or alternate modalities.

Distinction between carcinoma cells and mesothelial cells in serous effusions. Usefulness of immunohistochemistry.

The usefulness of an immunoperoxidase battery to distinguish carcinomatous from benign effusions was examined. Cell block sections from 90 previously diagnosed effusions were stained with antibodies to Leu-M1, B72.3, epithelial membrane antigen (EMA), carcinoembryonic antigen (CEA) and vimentin. The 90 cases comprised 69 carcinomas (23 mammary, 16 ovarian, 10 pulmonary, 7 gastrointestinal [GI] and 13 others), 2 malignant mesotheliomas and 19 cases with reactive mesothelial cells only. EMA and vimentin were the most useful markers for distinguishing carcinoma cells from reactive mesothelial cells. EMA reacted with 86% of the carcinomas while vimentin reacted with 90% of the reactive cases. Leu-M1, B72.3 and CEA, although generally less sensitive than EMA, were also helpful in this regard. Additionally, the use of Leu-M1 and CEA together may help to distinguish pulmonary from GI carcinomas.

Transthoracic needle aspiration biopsy in Wegener's granulomatosis. Morphologic findings in five cases.

Percutaneous needle aspiration biopsies of the lung from five patients with Wegener's granulomatosis were reviewed. Three of the patients presented with the generalized form of the disease while two presented with the limited pulmonary form; one of the latter subsequently developed disseminated disease. The morphologic findings in the pulmonary aspirates were similar in all cases. The cytologic preparations contained neutrophils entrapped within necrotic debris plus scattered but prominent histiocytic giant cells, which often had nuclei arranged in rings or horseshoes, in a background of lymphocytes, epithelioid histiocytes and reactive pneumocytes. Cell block preparations showed discrete areas of necrosis containing a neutrophilic infiltrate and focally palisaded by epithelioid histiocytes. The intervening viable tissue contained prominent histiocytic giant cells and chronic inflammatory cells enmeshed in a fibrous matrix. One cell block contained a small artery with a small focus of possible granulomatous arteritis. While an open lung biopsy is generally required for a definitive diagnosis, the pathologist may encounter unsuspected Wegener's granulomatosis in a needle aspirate. Recognition of the findings observed in these cases should alert the pathologist to the possibility of Wegener's granulomatosis so that an open lung biopsy can be performed if clinically indicated and cytotoxic therapy can be promptly instituted if the diagnosis of this entity is confirmed.

Pulmonary spindle cell carcinoid. Needle aspiration biopsy, histologic and immunohistochemical findings.

Six pulmonary spindle cell carcinoids were reviewed. The patients were asymptomatic women ranging from 56 to 76 years of age. Four cases were diagnosed or suspected by percutaneous needle aspiration biopsy. The four patients treated by wedge resection or lobectomy showed no recurrence during the followup period; one patient was followed radiologically without resection for over five years, during which time the lesion remained stable. The cytologic preparations showed groups and single oval or elongated cells that had nuclei with finely granular, evenly dispersed chromatin, usually one small nucleolus and easily disrupted, finely granular cytoplasm. The histologic sections showed circumscribed or infiltrative neoplasms growing as sheets or vaguely organoid cell masses with vascular, focally hyalinized stroma. Immunoreactivity for chromogranin, neuron-specific enolase, synaptophysin, S-100 protein and Leu-7 was typically present; bombesin, serotonin, insulin and calcitonin were focally present in some cases. No reactivity for adrenocorticotropic hormone, somatostatin, gastrin, vasoactive intestinal polypeptide, pancreatic polypeptide, low-molecular-weight cytokeratin (MAK-6) or carcinoembryonic antigen was observed.

Cytologic features of prostatic adenocarcinoma in urine: a clinicopathologic and immunocytochemical study.

Cells of adenocarcinoma of the prostate (ACP) are infrequently shed in urine. We examined the clinicopathologic features of 22 patients with ACP and tumor cells in urine. Patients typically were clinical stage C or D and had hematuria (13 cases, 59%) and/or obstruction (11 cases, 50%). Prostatic palpation or instrumentation preceded collection of 15 urine specimens. Histologically, tumors were high grade (Gleason score 7-10) and extensive, with involvement of prostatic ducts and acini (10 cases, 45%) and prostatic urethra (5 cases, 23%). Cytologically, the background was clean, and neoplastic cells appeared singly, in loose clusters, as large "casts," or, rarely, in papillary structures. The cells were small, round to oval, with a moderate amount of finely granular or vacuolated cytoplasm; nuclei were generally round with a thin, often irregular membrane, finely granular chromatin, and a single prominent nucleolus. Immunoperoxidase staining for prostatic acid phosphatase and prostate-specific antigen was useful in distinguishing ACP from transitional cell carcinoma.

Fine-needle aspiration biopsy of the pancreas: a study of 61 cases.

Eighty-six fine-needle aspirates (FNAs) of pancreas from 74 patients were reviewed. Histological confirmation or clinical follow-up of the final diagnosis was available in 61 aspirates from 49 patients. Of 42 proven malignant cases, FNAs were diagnosed as positive in 21 (50%), suspicious in 4 (9.5%), negative in 12 (28.6%), and unsatisfactory in 5 (11.9%). Of 19 proven benign cases, FNAs were diagnosed as negative in 15 (78.9%) and unsatisfactory in 4 (21%). This resulted in a 50% sensitivity, a 100% specificity, a diagnostic efficiency of 59%, a predictive value of a positive test of 100%, and a predictive value of a negative test of 55.6%. Thirty-six primary pancreatic adenocarcinomas and six metastatic tumors to the pancreas were encountered. Benign cases were attributed to anatomical pancreatic variants, acute pancreatitis, abscess, chronic pancreatitis, and pseudocysts. Pancreatic FNA was safe, accurate, and relatively inexpensive, but it was relatively insensitive in the diagnosis of malignancy.

Uterine tumor resembling an ovarian sex-cord tumor: report of a case of an endometrial stromal tumor with foam cells and ultrastructural evidence of epithelial differentiation.

Uterine tumors resembling ovarian sex-cord tumors are of uncertain histogenesis. We report such a neoplasm in which epithelial features observed by light microscopy were confirmed by electron microscopy and in which foam cells resembling those present in the stroma of hyperplastic endometria and in carcinoma represented a conspicuous intrinsic component. The lesion is interpreted as arising from endometrial stroma or multipotential uterine mesenchyme that has differentiated toward endometrial stroma and epithelium. The relationship of these uterine tumors to ovarian sex-cord stromal tumors and plexiform tumorlets is discussed.

The clinical and histologic spectrum of endometrial stromal neoplasms: a report of 41 cases.

Clinical and pathological features of 41 homologous uterine stromal tumors classified by the criteria of Norris and Taylor were reviewed. These included stromal nodules (12 cases), endolymphatic stromal myosis (20 cases), and stromal sarcoma (nine cases). Patients ranged in age from 18 to 79 with a median of 45 years. Symptoms were similar in all three forms and included vaginal bleeding (63%), pelvic pain (11%), or an abdominal mass (6%), while 26% of patients were asymptomatic. Tumors characteristically resembled endometrial stroma histologically, but variations included hemangiopericytoma and "sex-cord-like" patterns, hyalinization, and foam cells. A sex-cord-like pattern was seen only with stromal nodules and endolymphatic stromal myosis. Necrosis was seen in all three lesions, whereas nuclear anaplasia was seen only with stromal sarcoma. Follow-up ranging from 2 months to 12 years (median interval: 5 years) was obtained in 23 cases. No recurrences were recorded among six stromal nodules. Endolymphatic stromal myosis behaved as an indolent low grade malignancy, with three recurrences but no deaths among 13 patients; these occurred at 3 to 7 years after initial diagnosis. Stromal sarcoma behaved as a high grade malignancy, with two deaths among five patients with follow-up, both occurring within 8 months of diagnosis.

Cardiac papilloma. A case report with evidence of thrombotic origin.

A pulmonic valve cardiac papilloma was found in a patient with coagulopathy and disturbed right ventricular hemodynamics. Fibrin was demonstrated within the cores of the papillae, lending further support to the thrombotic derivation of these lesions. The tumor's papillary configuration was thought to be the result of molding by the turbulent blood flow at that site.