Science, Medicine, and Cytology: an educational program of the Diversity, Equity, and Inclusion Committee of the American Society of Cytopathology.

INTRODUCTION: As our field of pathology continues to grow, our trainee numbers are on the decline. To combat this trend, the ASC Diversity, Equity, and Inclusion Committee established the Science, Medicine, and Cytology SumMer Certificate program to improve exposure to pathology/cytopathology with a focus on diversity, equity, and inclusion. Herein, we report our findings of the first 2 years of the program. MATERIALS AND METHODS: An online course was developed targeting students who are underrepresented in medicine at the high school and college level. It consisted of several didactic sessions, presenting the common procedures involving cytopathologists and cytologists. Interviews with cytopathologists were also included. Participants were surveyed for demographic information and provided course evaluations. RESULTS: In the first year of the program (2021), 34 participants completed the program, which increased to 103 in 2022. In both years there was a diversity in participant demographic backgrounds; however, only a minority of participants self-identified as being underrepresented in medicine. A vast majority (>85%) of participants in both years were high school or college students. In 2021, 100% of participants stated that the program format was effective and 94% thought the content was appropriate for their level of education; in 2022 the results were similar. In 2021, 66% considered health care as a potential career; this value increased in 2022 to 83%. In 2021 and 2022, 31% and 38%, respectively, considered cytology as a career. CONCLUSIONS: Evaluations were excellent, generating interest in cytopathology. Barriers in reaching underrepresented minorities exist and additional work is needed. Expansion to a wider audience may increase outreach.

Myeloid sarcoma resulting in a small bowel obstruction with multiple site involvement including ileum and appendix.

Myeloid sarcoma (MS) is a rare extra-medullary solid tumor of immature myeloid cells. While it can be an isolated diagnosis, MS is frequently associated with acute myeloid leukemia, chronic myeloid leukemia and myelodysplastic disorders. Although there have been few cases documented that demonstrate the presence of MS in multiple organs at presentation, concomitant involvement of ileum and appendix has never been described. We treated a patient who presented with a small bowel obstruction at the ileum secondary to MS with involvement of the appendix. The patient subsequently underwent a bone marrow biopsy which was negative for evidence of leukemia. He began treatment with induction chemotherapy.

Fine needle aspiration of thyroid nodules in the pediatric population: a 12-year cyto-histological correlation experience at North Shore-Long Island Jewish Health System.

BACKGROUND: Diagnostic evaluation of thyroid nodules by FNA is used in the clinical management triage based on the knowledge of the rate of malignancy of each diagnostic category. The Bethesda System for Reporting Thyroid Cytopathology was published in 2007 by the National Cancer Institute (NCI). Using this classification, we studied our institution's experience in the pediatric population calculating the rate of malignancy for each diagnostic category, comparing our findings to our general patient population and that of the literature. METHODS: 13,312 thyroid FNAs were performed at our institution between 1998 and 2010. 282 cases were from patients under 19 years of age. We reviewed and reclassified these cases using the new NCI categories, and pursued cytology-surgical follow-up. RESULTS: Of the 282 FNA cases, 20.92% (59) were classified as unsatisfactory (U), 48.22, % (136) benign (B), 2.12% (6) Atypia of undetermined significance (AUS), 14.18% (40) suspicious for follicular neoplasm (FN), 2.12% (6) suspicious for malignancy (SM) and 12.41% (35) positive for malignancy (P). The U-category was further classified into nondiagnostic (ND) 12.41% (35) and cysts (C) 8.51% (24). Seventy-four children had surgical follow-up. The rates of histologically confirmed malignancy were 10% in U (1/10), 0% in B (0/17), 50% in AUS (2/4), 39% in FN (7/18), 100% in SM (4/4) and 100% in P (24/24) categories respectively. Among the U category, malignancy rate was 0% for the ND category and 25% for the C category. CONCLUSIONS: To our knowledge, this is the first study to apply the NCI categories to the pediatric population. The rate of malignancy in the U category was only seen in the specimens with cystic component. AUS and FN categories had a higher malignancy rate (50 and 39% respectively) as compared with that of the general population (15 and 30% respectively). Given that the rates of malignancy are higher for cysts and AUS, the literature recommendation to "follow-up and repeat" may not apply to the pediatric population. Surgery may be reasonable in these categories instead.

Ossifying fibromyxoid tumor of the breast mimicking fibroadenoma: a case report and differential diagnoses.

An 80-year-old woman presented with a palpable mass in the right breast. Mammographic findings were consistent with calcified fibroadenoma. An ultrasound was performed that showed a solid nodule with peripheral calcification. A core biopsy was obtained that revealed a spindle cell proliferation with a shell of mature bone. The histologic features, in combination with immunohistochemical studies, were those of an ossifying fibromyxoid tumor. Complete excision of the specimen further confirmed the diagnosis. To the best of our knowledge, this is the first reported case of ossifying fibromyxoid tumor occurring in the breast. We review the current literature on ossifying fibromyxoid tumor and discuss the differential diagnoses when confronted with bland spindle cells on a core biopsy of the breast.

Utility of immunocytochemistry in diagnosing leptomeningeal metastases from an intrahepatic cholangiocarcinoma.

Isolated spinal leptomeningeal metastases (LMM) without brain metastases are infrequent, accounting for about 1% of all solid tumors. In LMM, cerebrospinal fluid (CSF) analyses are mostly abnormal. Demonstrations of intrathecal tumor markers are highly suggestive, but only a positive cytology is diagnostic. The initial CSF cytology can give a false negative result in up to 40-50% of patients with pathologically proven LMM on autopsy. We report a case of intrahepatic cholangiocarcinoma with spinal LMM confirmed using cytokeratin7 and pancytokeratin (AE1/AE3) immunocytochemical studies on paucicellular cerebrospinal fluid cytospin preparation. Given the paucicellularity of the smears and difficult morphologic categorization, immunocytochemistry is vital for confirmatory diagnosis and can help reduce false negative results. To the best of our knowledge this is the first case report of cytologically confirmed LMM from an intrahepatic cholangiocarcinoma while the patient was undergoing treatment.

Cutaneous metastasis as an initial presentation of lung adenocarcinoma with KRAS mutation: a case report and literature review.

Cutaneous metastasis as an initial presentation occurs in 0.8% of patients with internal malignancies, and is poorly understood in its molecular pathogenesis. We reported a case in which a 61-year-old male patient initially presented with rapidly growing skin nodule on his left chest wall, then developed dyspnea and loss of weight. Echocardiogram showed a large pericardial effusion with right ventricular collapse. PET/CT revealed moderate pleural effusion and multiple lymphadenopathies with hypermetabolic concentration of radiotracer in the lymph nodes as well as in the chest wall skin mass. Biopsy of the skin mass and pericardial/pleural fluids revealed metastatic adenocarcinoma consistent with lung primary with KRAS mutation. Palliative chemotherapy was administered without resulting in any improvement. This is the first case report to show that KRAS-mutant lung adenocarcinoma can be associated with cutaneous metastasis.

Pulmonary adenofibroma: cytologic and clinicopathologic features of a rare benign primary lung lesion.

We report a case of pulmonary adenofibroma in a 29-year-old female found by CT scan during work-up for midline chest pain. To our knowledge, the cytological features of this entity have not been previously reported. Cytology demonstrated bland epithelial and stromal cells of varying size without karyorrhexis, pyknosis, or necrosis and with very rare mitoses. Stromal cells were present as either naked bipolar nuclei, as spindle cells with fragile eosinophilic cytoplasm, or as rare larger carrot shaped nuclei. Epithelial cells were present as small loosely cohesive groups with smooth round nuclei and moderate amounts of cytoplasm. Histologically, this lesion consisted of a leaf-like fibroepithelial pattern in which the clefts were lined by a single layer of cuboidal epithelium reminiscent of adenofibroma occurring in the female genital tract. Immunohistochemical analysis demonstrated epithelium that stained positively for pan-cytokeratin and TTF-1. The stroma stained positively for vimentin and desmin, and was weakly positive for SMA-1. The lesion was confirmed to be pulmonary adenofibroma with a smooth muscle component. The differential diagnosis for this lesion includes, but is not limited to, pulmonary hamartoma, pulmonary blastoma, adenomyofibroma, synovial sarcoma, and visceral metastases. It is important for cytopathologists to be aware of this benign entity because it can be encountered on lung FNA specimens. Considering this benign lesion in the differential diagnosis may help plan for minimal lung resection. Confirmatory intraoperative frozen section is a reasonable option.

Clinical evaluation of a novel bipolar radiofrequency ablation system for renal masses.

UNLABELLED: What's known on the subject? and What does the study add? With the advancement of minimally invasive surgery, the management of small renal masses (SRM) has dramatically changed. Ablative technology such as radiofrequency ablation (RFA) and cryoablation have emerged as viable alternative modalities to extirpative surgery. RFA is one of the most studied and applied energy-based, needle-ablative treatment modalities, with encouraging mid- and long-term oncological outcomes. Monopolar devices have several shortcomings. The electrodes are susceptible to the cooling effect of nearby blood vessels that act as a 'heat sink', limiting the extent of tissue ablation and forming lesions with asymmetric borders and 'skip lesions'. Therefore, it is difficult to monitor and accurately predict the size of ablated lesions. A novel bipolar radiofrequency ablation (BRFA) device has been recently developed to address concerns with monopolar systems (Trod Medical, Paris, France). The BRFA system addresses the limitations of monopolar RFA, in terms of lesion size, targeting, consistency and concerns about cell death in the ablated area. We evaluated the BRFA device in 10 patients undergoing laparoscopic partial or radical nephrectomy. The present study demonstrates the safety and efficacy of a novel BRFA device. A BRFA device can produce a defined reproducible lesion with a precise transition zone to normal tissue. The area of ablated tissue exhibited completely devitalized cells and precise transition zone. With these characteristics, the potential advantages of this new technology during RFA ablation of SRM include less collateral damage and more complete ablation without skip lesions. This has the potential to lower rates of local recurrence and reduce incidence of skin burns. Further follow-up studies are necessary to determine its oncological efficacy. OBJECTIVE: To evaluate a novel bipolar radiofrequency ablation (BRFA) system for the destruction of kidney tumours in patients. MATERIALS AND METHODS: Bipolar radiofrequency ablation (BRFA) was used to ablate renal masses in 10 patients undergoing laparoscopic radical or partial nephrectomy. The probe was placed percutaneously and laparoscopically guided into the tumour after routine laparoscopic exposure. The electrical current was continuously adjusted by the generator to overcome disruption from increasing impedance created from desiccated tissue. The specimens were then excised in routine fashion and analysed by a single pathologist. Lesion size and shape, and size of the transition zone to viable tissue were measured via nicotinamide adenine dinucleotide (NADH) staining. RESULTS: Ablation was successful in all 10 tumours. Mean time to set up and place the probe was between 2 and 4 min. Duration of ablation was 200 s. None of the ablated tissue showed signs of viable cells by histological examination and NADH staining. The mean size of the ablation zone was 6.26 cm(3), with regular borders and a tapered cylindrical shape similar to the shape of the outer coil. The width of the transition zone, or area spanning complete tissue ablation to the first viable cells, ranged from 10 to 60 µm. There were no complications noted due to the ablation. CONCLUSIONS: A BRFA device can produce a defined reproducible lesion with a precise transition zone to normal tissue. The area of ablated tissue exhibited completely devitalized cells and precise transition zone.

Endobronchial ultrasound-guided transbronchial needle aspirate (EBUS-TBNA): a proposal for on-site adequacy criteria.

This is a retrospective study of 48 patients who underwent EBUS-TBNA procedure between the periods January 2008 to September 2009 at Long Island Jewish Medical Center. The study was undertaken with the following objectives: First, to define practical and useful on-site adequacy criteria for EBUS-TBNA samples; Second, to understand the diagnostic pitfalls associated with accurate interpretation of EBUS-TBNA samples. EBUS-TBNA procedure was able to diagnose 24/48 (50%) patients with malignancy, 1/48 (2%) suspicious for malignancy, 9/48 (19%) with granulomatous process, and 9/48 (19%) negative for disease. Only five cases (10%) could not be diagnosed with this procedure. Based on our experience, any smear with presence of > 5 low power fields (×100) with ≥ 100 lymphocytes in each and containing < 2 groups of bronchial cells/low power field (×100) can be considered adequate for evaluation. Also, the presence of germinal center fragments renders a smear adequate for evaluation, irrespective of the above mentioned criteria. Adequacy criteria are to be applied only to the smears not showing any identifiable pathology such as malignancy or granuloma. An understanding of diagnostic pitfalls associated with accurate interpretation of EBUS-TBNA samples is essential to avoid false-positive and false-negative diagnosis. To conclude, an effective communication between the clinician and cytologist, an algorithmic approach to diagnosis, and the on-site adequacy criteria proposed in this study can markedly improve the diagnostic yield of the procedure.

Breast cancer in a case of Shwachman Diamond syndrome.

Shwachman Diamond syndrome (SDS) is a rare inherited bone marrow failure syndrome (IBMFS) characterized by neutropenia, exocrine pancreatic dysfunction, and cancer predisposition. Patients are at risk for myelodysplastic syndrome (MDS) and acute myelogenous leukemia (AML) but, unlike other IBMFS, there have been no reported cases of solid tumors. We report a novel case of a solid tumor in a patient with SDS and biallelic mutations in the Shwachman Bodian Diamond Syndrome gene (SBDS). Whether the development of breast cancer in this patient is due to SDS or an isolated case due to unknown factors requires further study.

Clinical impact of second opinion in thyroid fine needle aspiration cytology (FNAC): A study of 922 interinstitutional consultations.

Interinstitutional consultation in pathology has shown to improve patient safety by detecting interpretive errors that may significantly impact clinical management. We conducted a study of 922 cases of thyroid FNAC slides, referred to our institution over a 2-year period, to assess the magnitude of discrepancies and determine the clinical impact of second opinion. Disagreements were categorized as none, minor or major, the latter two defined as one- or two-step deviations respectively on the NCI diagnostic categories scale. There were 122 disagreements (13%), including 44 major and 78 minor. Seventy-five patients underwent a change in management based on second opinion, in conjunction with clinical and radiologic findings (age, size of nodule, family history, ultrasonographic appearance, and solitary versus multiple nodules). The second opinion was supported on follow-up in 57% of major discrepancies, and the initial diagnosis was concurrent with the surgical diagnosis in 7% cases. The remainder (36%) of major discrepancy cases did not undergo surgery, precluding tissue confirmation. Critics have alleged increased costs due to interinstitutional consultations. However, cost avoidance from lost wages, potential surgical complications, and litigation is not easily quantified. Using a simplified calculation to objectively measure the costs associated with changed diagnoses, we estimate that second opinion of these 922 cases resulted in potential cost saving of $940,166 based on current Medicare reimbursement codes. Our study indicates the need for a quality-control program of outside thyroid FNA slides, especially in "high discrepancy categories" as discussed in the article.

Monophasic parapharyngeal synovial sarcoma diagnosed by cytology, immunocytochemistry, and molecular pathology: case report and review of the literature.

Synovial sarcoma (SS) of the head and neck region are rare, accounting for less than 10% of all head and neck soft tissue sarcomas. A limited number of SS have been reported in the parapharyngeal space and these reports have all been based on histological examination of resection material. The diagnosis of monophasic SS on cytology is extremely difficult. We report the first case where a SS was correctly diagnosed on a fine needle aspirate by cytology with the assistance of immunocytochemistry and fluorescence in situ hybridization. We will emphasize the importance of ancillary techniques, such as immunocytochemistry and cytogenetic/molecular pathology, in avoiding diagnostic pitfalls and correctly diagnosing monophasic SS on cytologic material. We will propose an algorithmic approach to accurately diagnose parapharyngeal spindle cell neoplasms with the use of appropriate ancillary studies in conjunction to morphological features.

Cutaneous myoepithelioma with a plexiform pattern of growth: a case report.

Cutaneous myoepithelioma, a recently recognized, rare but well-characterized entity, is comprised solely of myoepithelial cells. In this report, we describe a cutaneous myoepithelioma with a plexiform pattern of growth in the scapular region of a 58-year-old woman.

Granular cell astrocytoma.

Granular cell astrocytoma (GCA) is a rare type of malignant brain tumor with distinct morphologic features and aggressive clinical behavior. Almost all GCAs occur in the cerebral hemispheres. It is characterized by a prominent component of bland-looking granular cells. The tumor cells are usually positive for glial fibrillary acidic protein, S100, CD68, and epithelial membrane antigen. The most important differential diagnoses include a number of reactive lesions such as cerebral infarction, multiple sclerosis, and progressive multifocal leukoencephalopathy. Electron microscopic study reveals that the granules of GCA correspond to an increased number of intracytoplasmic lysosomes. The histogenesis of GCA is still unclear, but most people believe it originates from astrocytes. Loss of 9p and 10q were identified in almost all cases of GCA, but they are not specific for this tumor. Surgical excision plus postoperative chemotherapy or radiotherapy is the choice for most patients with GCA.

Immunophenotypic characterization of anal gland carcinoma: loss of p63 and cytokeratin 5/6.

Anal gland carcinoma (AGC) is a rare perianal invasive cancer composed of tubular glands lined by cuboidal epithelium. The clinical features and histogenesis of AGC are not well understood and its origin from anal glands is often difficult to prove. Little is known about immunophenotypic features of AGC that could be useful in establishing the diagnosis. This study evaluated the immunohistochemical profile of 2 cases of AGC in comparison to anal glands from 11 hemorrhoidectomy specimens. Sections from the specimens were routinely processed and immunostained using commercial antibodies to cytokeratin (CK) 7, CK20, CK5/ 6, p63, CDX2, smooth muscle actin, calponin, heavy chain smooth muscle myosin, p53, and p16. In case 1 of AGC, radiation and chemotherapy preceded an abdominoperineal resection. In biopsies from this case, the neoplastic anal glands had a tubular pattern, whereas most glands in the resection specimen exhibited mucinous features. The histologic pattern in case 2 was tubular. Normal anal glands showed immunoreactivity for myoepithelial and basal cell markers CK5/6 and p63 in basal and parabasal cell layers and for CK7 in superficial cell layers. In contrast, both cases of AGC were negative for CK5/6 and p63 and were diffusely positive for CK7. Normal glands and both cases of AGC were negative for the intestinal differentiation marker CDX2, CK20, smooth muscle actin, calponin, smooth muscle myosin heavy chain, p16, and p53. Our data suggest that loss of p63 and CK5/6 expression is a feature of AGC. Anal gland carcinoma shares negativity for CDX2 and CK7+/CK20- profile with normal anal glands. No evidence of myoepithelial cells was found in normal or malignant anal glands. These data may be useful in establishing the diagnosis of AGC.

Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care.

OBJECTIVES: To determine whether an in-home palliative care intervention for terminally ill patients can improve patient satisfaction, reduce medical care costs, and increase the proportion of patients dying at home. DESIGN: A randomized, controlled trial. SETTING: Two health maintenance organizations in two states. PARTICIPANTS: Homebound, terminally ill patients (N=298) with a prognosis of approximately 1 year or less to live plus one or more hospital or emergency department visits in the previous 12 months. INTERVENTION: Usual versus in-home palliative care plus usual care delivered by an interdisciplinary team providing pain and symptom relief, patient and family education and training, and an array of medical and social support services. MEASUREMENTS: Measured outcomes were satisfaction with care, use of medical services, site of death, and costs of care. RESULTS: Patients randomized to in-home palliative care reported greater improvement in satisfaction with care at 30 and 90 days after enrollment (P<.05) and were more likely to die at home than those receiving usual care (P<.001). In addition, in-home palliative care subjects were less likely to visit the emergency department (P=.01) or be admitted to the hospital than those receiving usual care (P<.001), resulting in significantly lower costs of care for intervention patients (P=.03). CONCLUSION: In-home palliative care significantly increased patient satisfaction while reducing use of medical services and costs of medical care at the end of life. This study, although modest in scope, presents strong evidence for reforming end-of-life care.

Physical activity in older, rural, Hispanic, and non-Hispanic white adults.

PURPOSE: Understanding variations in physical activity patterns is important for planning health interventions. This study describes age-related change in physical activity in 903 rural Hispanic and non-Hispanic white (NHW) adults age 55-80. METHODS: The Physical Activity History assessed 13 categories of productive and recreational activity during the past year with up to four assessments per participant from 1987 to 1998. RESULTS: The most common activities were walking and home maintenance/gardening. Productive and recreational physical activity levels were lower in women than men (P < 0.0001), and within each gender group Hispanics had lower levels of both activity types than NHW (P values less than 0.05). In men, productive activity steadily declined with age in NHW and Hispanics. Recreational activity increased slightly until age 63, then decreased after age 70. In women, productive activity initially stayed stable then decreased in NHW after age 63, and in Hispanics it decreased at younger ages before stabilizing after age 70. Recreational activity levels decreased steadily with age in all women, with a steeper rate of decline in NHW than Hispanics. In both ethnic groups, activity levels were lower in diabetics than nondiabetics, except for recreational activity in women where levels did not differ by diabetes status. CONCLUSIONS: The most common activities were similar to other studies of older adults, both recreational and productive activities contributed to total activity, and physical activity decreased in all gender-ethnic subgroups with age. Hispanic women reported the lowest activity levels. Interventions to maintain or increase recreational activity may need to target women at an earlier age than men.

Comparison of laparoscopic saline infused to dry radio frequency ablation of renal tissue: evolution of histological infarct in the porcine model.

PURPOSE: We investigated and compared the gross and histopathological features of radio frequency (RF) ablated renal tissue using saline infused RF ablation (RFA) vs dry RFA in a porcine model. MATERIALS AND METHODS: Ten porcine kidneys underwent laparoscopic RFA. The lower and upper poles of each right kidney were treated with 1 and 2 cycles of saline augmented (wet) RFA, respectively. The upper pole of each left kidney was RF ablated without saline infusion (dry RFA) and a control lesion was created in the lower pole. The animals were sacrificed immediately after ', 2 and 9 days after (subacute), and 14 and 21 days after (chronic) treatment, respectively. Gross pathological and histological changes caused by the different RF treatments were compared. RESULTS: Mean time to attain target temperature was shorter with wet than with dry RFA. Grossly the lesion sizes achieved were larger using wet RFA but independent of the number of wet RFA treatment cycles. Gross lesion sizes decreased with time for each treatment modality. No histopathological differences were seen between the 2 RFA treatment modalities as well as between 1 vs 2 cycles of wet RFA. In the acute phase hematoxylin and eosin staining of ablated tissue revealed focal areas of alterations in renal tubular histology. However, nicotinamide adenine dinucleotide staining of corresponding areas confirmed the lack of cellular viability except for glomeruli. In the subacute phase there were focal coagulation necrosis and thrombosed blood vessels. Within the necrotic areas the glomeruli were the last structures to lose viability. In the chronic phase fibrosis with decreased lesion size was seen. Nicotinamide adenine dinucleotide staining demonstrated that the cellular kill was permanent during the entire study period. CONCLUSIONS: The effects of RFA of renal tissue has 2 phases, namely initial direct thermal ablation causing acute cell death and a later subacute phase causing subsequent infarction of the distal arterial vascular supply to the ablated region, resulting in more cell death and coagulative necrosis. Glomeruli are the last structures to lose viability in necrotic areas. Most importantly cellular death caused by RFA is permanent.

Improving care for nursing home-acquired pneumonia in a managed care environment.

OBJECTIVE: To characterize care of nursing home residents who became ill with nursing home-acquired pneumonia (NHAP) in a group-model, nonprofit HMO, and to pilot-test a strategy to implement evidence-based NHAP care guidelines. STUDY DESIGN: Medical record review and intervention pilot test. METHODS: Nursing home medical records of 78 patients who developed NHAP in 6 homes where the HMO contracts for Medicare services were reviewed for demographics, functional status, comorbidity, NHAP severity, care processes, and guideline compliance. The intervention, combining organizational change (facilitating immunization and providing appropriate emergency antibiotics) and education (quarterly in-services for nursing and aide staff), was pilot-tested for 7 months in 1 facility. Measures of baseline and intervention guideline adherence at that facility were compared with Fisher's exact test. RESULTS: Among the patients with NHAP, 83% had a response from their physician in less than 8 hours, 82% were treated with an antibiotic that met spectrum recommendations, and 74% were able to swallow were treated with oral antibiotics. However, few patients had documentation of influenza and pneumococcal vaccination; less than half the direct care staff had been vaccinated; and nursing assessments were incomplete for 23%. At the pilot-test facility, improvement was seen in influenza vaccination (14% to 52%, P = .01) and use of the most appropriate antibiotics (47% to 85%; P = .03). The guideline adherence score improved from 52% to 63% (P = .04). CONCLUSION: Use of a multidisciplinary, multifaceted intervention resulted in improvement in quality of care for nursing home residents who become ill with pneumonia.