Evaluation of lymphocytic thyroiditis in children with quantitative gray-scale ultrasound echo intensity using a PACS-based tool.

PURPOSE: To evaluate diagnostic performance of PACS-based quantitative gray-scale ultrasound as an objective method in evaluation of pediatric thyroiditis. METHODS: Quantitative measurements of the echo-intensity level of the thyroid were obtained from ultrasound images, retrospectively using a PACS-based tool in 37 children with the tissue-proven diagnosis. Thyroid/muscle ratio was calculated by dividing the mean echo intensity of thyroid by that of adjacent strap muscle. Heterogeneity index (HI) was calculated by dividing thyroid standard deviation (SD) by thyroid mean values. For qualitative evaluation, two radiologists independently reviewed ultrasounds twice for the presence of thyroiditis. A consensus session was performed for patients for whom there was disagreement. Intra- and inter-observer reliability were assessed. Thyroid/muscle ratio and HI were correlated with final pathology. RESULTS: Lymphocytic thyroiditis was found by histopathology in 19/37 (51%). No significant difference between thyroiditis and normal thyroid groups was found for either thyroid/muscle ratio (1.51 and 1.62, respectively, p = .82) or HI (0.23 and.23, respectively, p = .37). A larger proportion of patients for whom the consensus review indicated thyroiditis were confirmed by histopathology than would be expected by chance alone (12/19 (63%), p = .03). There was fair inter-observer agreement (κ with 95% confidence intervals of 0.36 (0.14-0.57), p = .004) and slight intra-observer agreement for each radiologist (κ with 95% confidence intervals of 0.13 (0.17-0.43), p = .39 and 0.17 (0.15-0.49), p = .31). CONCLUSION: Quantitative gray-scale echo intensity analysis of US was not sufficient to diagnose thyroiditis in a pediatric population. Consensus qualitative analysis of ultrasound was more consistent with pathological diagnosis.

Fine-needle aspiration specimens of 3 cases of intra-abdominal Rosai-Dorfman disease with comprehensive review of the literature.

INTRODUCTION: Rosai-Dorfman disease (RDD) is a rare usually self-limited non-Langerhans cell histiocytosis of unknown etiology. Nodal and extranodal RDD appear to represent distinct conditions with different molecular alterations and prognosis. They also pose different diagnostic challenges on biopsies and fine-needle aspiration (FNA) cytology. The aim of this study was to report on 3 cases of intra-abdominal RDD and perform an extensive review of the literature on FNA findings of RDD. MATERIALS AND METHODS: We reviewed FNA specimens from cases diagnosed histologically or cytologically as RDD during the past 10 years. We searched the PubMed and Google Scholar databases for cases of RDD sampled by FNA. RESULTS: We identified 3 cases of intra-abdominal RDD, involving the kidney, periportal lymph node, and pancreas. FNA of the latter was hypocellular with fibrosis and was nondiagnostic. FNA of the first 2 yielded hypercellular smears that were diagnosed as RDD due to the identification of emperipolesis occurring in large uni- or binucleated histiocytes with large nuclei, fine chromatin, and prominent nucleoli in smears and cell-block sections. Immunohistochemistry showed positive staining for S100 and CD68 and negative staining for CD1a. The large histiocytes with emperipolesis were more difficult to identify histologically and their demonstration required immunohistochemical stains. CONCLUSION: Our experience and an extensive review of the literature suggest that extranodal RDD can be diagnosed on FNA, and that the recognition of histiocytes with emperipolesis may be less challenging cytologically than histologically. The fibrosis frequently seen in extranodal RDD may lead to nondiagnostic aspirates, however.

A BAFfling liver aspirate: Metastatic high grade SMARCA4 deficient undifferentiated gastroesophageal junction carcinoma masquerading as a hematolymphoid malignancy.

Undifferentiated malignant SMARCA4-deficient neoplasms are rare, recently characterized, high grade, potentially lethal malignancies. Such tumors are characterized by the loss of BRG1 encoded by SMARCA4, a key component of the Switch/Sucrose Non-Fermenting (SWI/SNF) chromatin remodeling complex. As this complex, also referred as BAF (BRG1/BRM associated factors) complex, is involved in the epigenetic control of hundreds of genes, including those involved in lineage-specific differentiation, BAF-deficient tumors, show minimal or no differentiation and are difficult to classify. Their fine needle aspiration (FNA) cytologic features are still poorly defined. Here, we describe a 70-year-old man who presented with thickening of the wall of the distal esophagus and stomach and multiple liver and lung lesions. Liver FNA showed relatively uniform dispersed malignant cells with high nucleus: cytoplasm ratio, scant microvacuolated cytoplasm, eccentric nuclei and prominent nucleoli. Mitoses, necrotic debris, nuclear streak artifact, "ghost cells" and focal rhabdoid cytoplasmic inclusions were also present. The liver core biopsy and GI biopsies demonstrated sinusoidal and respectively submucosal involvement by a high grade undifferentiated malignant neoplasm. The tumor cells were negative for all applied markers on immunohistochemistry and flow cytometry, and only showed CD138 and weak PAX5 staining. After an initial diagnosis of hematolymphoid neoplasm, additional stains showed intact INI1 protein and loss of BRG1 protein immunoexpression, establishing the accurate diagnosis. This case highlights the difficulties and potential pitfalls encountered in the FNA diagnosis of BAF-deficient tumors, the accurate diagnosis of which is important due to their lack of response to conventional therapy and potential response to targeted therapy.

Noninvasive follicular thyroid neoplasm with papillary-like nuclear features in the pediatric age group.

BACKGROUND: The most common malignant thyroid neoplasm in children is papillary thyroid carcinoma (PTC). In 2015, the Endocrine Pathology Society introduced the terminology "noninvasive follicular thyroid neoplasm with papillary-like nuclear features" (NIFTP) to replace the noninvasive follicular variant of PTC. The objective of the current study was to evaluate previously diagnosed PTC in the pediatric population, reappraise it for NIFTP, and discuss the impact of NIFTP on the risk of malignancy (ROM) for each The Bethesda System for Reporting Thyroid Cytopathology category in the pediatric population. METHODS: The electronic databases of both study institutions were searched for all thyroidectomy specimens in patients aged <19 years from June 1, 2001 through June 1, 2016. The patient's age, sex, diagnosis, previous fine-needle aspiration cytology diagnosis, and follow-up were tabulated. Slides for available cases were reviewed and cases qualifying as NIFTP were separated. RESULTS: The cohort included 101 resected nodules; cytological diagnoses were available for 95 cases. These cases included diagnoses of nondiagnostic (5 cases; 5.2%), benign (21 cases; 22.1%), atypia/follicular lesion of undetermined significance (9 cases; 9.5%), follicular neoplasm/suspicious for follicular neoplasm (FN/SFN) (25 cases; 26.3%), suspicious for malignancy (7 cases; 7.4%), and malignant (28 cases; 29.5%). On the histological follow-up, 50 cases (49.5%) were benign, 49 cases (48.5%) were malignant, and 2 cases (1.9%) were NIFTP. These NIFTP cases originally were diagnosed as FNs on fine-needle aspiration cytology. The average ROM for FNs with and without NIFTPs was 28% and 25%, respectively CONCLUSIONS: According to our rate of 1.9% for NIFTPs on reappraisal for resected nodules, this entity is likely to be less frequent in the pediatric population due to the higher prevalence of PTCs and/or more aggressive variants. NIFTPs do not appear to affect the ROM for The Bethesda System for Reporting Thyroid Cytopathology categories in the pediatric population. However, large-scale studies are necessary to determine whether NIFTPs could affect the pediatric population. Cancer Cytopathol 2018;126:27-35. © 2017 American Cancer Society.

Presence of ulceration, but not high risk zone location, correlates with unfavorable histopathological subtype in facial basal cell carcinoma.

BACKGROUND: Basal cell carcinoma (BCC) has been stratified into low- and high-risk according to their propensity for local recurrence. Risk factors for recurrence include histologic subtype, anatomic location (i.e. H-zone of the face), horizontal diameter, and patient health status. OBJECTIVE: To assess if favorable (superficial, nodular, adenoid and trabecular) and unfavorable (infiltrative, morpheaform, micronodular, metatypical, basosquamous) histopathological subtypes of BCC do correlate with anatomic location on the face (facial high risk versus non-high risk zones). METHODS: Histopathological specimens of all facial BCCs, which were histopathologically diagnosed in the Pathology Department of Sisli Etfal Training Hospital, between the years 2008 and 2014 were retrospectively studied. Histopathological aggressive and non-aggressive subtypes as well as the presence of ulceration were correlated with facial high-risk (i.e. H-zone) and low risk anatomical locations. RESULTS: Of 184 BCC of unfavorable subtypes, 101 cases were identified in facial high-risk anatomical region (H-zone) compared to 83 cases at non H-zone (P = 0.553). On the other hand the ulceration rate was significantly higher for unfavorable histological subtypes than in the favorable histopathological subtype group (P = 0.042). Regarding anatomic site, ulceration frequency was not significantly different for the H-versus non-high risk zones (P = 0.335). CONCLUSIONS: A correlation of unfavorable histopathological subtype of BCC and high-risk anatomical location (i.e. H-zone) was not observed in our study. Our results however confirmed a significantly higher rate of ulceration in the subgroup of aggressive histopathological BCC forms. Thus, factors other than histopathological subtype (such as narrow excision margin related to difficult surgical technique in H-zone, microcirculation, vasculature and host inflammatory response) may be responsible for the high recurrence rate in facial H-zone-located BCCs.