Breast metastasis from vaginal cancer.

Vaginal cancer is a rare malignancy accounting for 1-2% of all pelvic neoplasms. Dissemination usually occurs through local invasion and rarely metastasises to distal locations. Metastasis of vaginal cancer to the breast is extremely infrequent and unique. A 66-year-old Asian woman presented with vaginal bleeding and was found to have a vaginal mass and a left breast mass. Pathological assessment of the biopsies revealed identical squamous cell characteristics of both masses. We describe a very rare and novel case of a distally located vaginal carcinoma with metastasis to the breast Federation of Gynecology and Obstetrics (FIGO) stage IV (FIGO IVB). Robot-assisted extrafascial total hysterectomy with local vaginal mass excision and partial mastectomy of the left breast were performed. After surgery, the patient underwent adjuvant chemotherapy followed by breast and pelvic radiotherapy, with maintained complete remission after 3 years of follow-up. This combination of findings and treatment is very distinct with a unique and favourable response.

p16 immunocytochemistry on cell blocks as an adjunct to cervical cytology: Potential reflex testing on specially prepared cell blocks from residual liquid-based cytology specimens.

BACKGROUND: p16 (INK4a) (p16) is a well-recognized surrogate molecular marker for human papilloma virus (HPV) related squamous dysplasia. Our hypothesis is that the invasive interventions and related morbidities could be avoided by objective stratification of positive cytologic interpretations by p16 immunostaining of cell block sections of cytology specimens. MATERIALS AND METHODS: Nuclear immunoreactivity for p16 was evaluated in cell block sections in 133 adequate cases [20 negative for intraepithelial lesion or malignancy, 28 high-grade squamous intraepithelial lesion (HSIL), 50 low-grade squamous intraepithelial lesion (LSIL), 21 atypical squamous cells, cannot exclude HSIL (ASC-H), and 14 atypical squamous cells of undetermined significance (ASCUS)] and analyzed with cervical biopsy results. RESULTS: (a) HSIL cytology (28): 21 (75%) were p16 positive (11 biopsies available - 92% were positive for cervical intraepithelial neoplasia (CIN) 1 and above) and 7 (25%) were p16 negative (3 biopsies available - all showed only HPV with small atypical parakeratotic cells). (b) LSIL cytology (50): 13 (26%) cases were p16 positive (12 biopsies available - all were CIN1 or above) and 37 (74%) were p16 negative (12 biopsies available - all negative for dysplasia. However, 9 (75%) of these biopsies showed HPV). (c) ASC-H cytology (21): 14 (67%) were p16 positive (6 biopsies available - 5 showed CIN 3/Carcinoma in situ/Ca and 1 showed CIN 1 with possibility of under-sampling. Cytomorphologic re-review favored HSIL) and 7 (33%) were p16 negative (5 biopsies available - 3 negative for dysplasia. Remaining 2 cases - 1 positive for CIN 3 and 1 showed CIN 1 with scant ASC-H cells on cytomorphologic re-review with possibility under-sampling in cytology specimen). (d) ASCUS cytology (14): All (100%) were p16 negative on cell block sections of cervical cytology specimen. HPV testing performed in last 6 months in 7 cases was positive in 3 (43%) cases. CONCLUSION: p16 immunostaining on cell block sections of cervical cytology specimens showed distinct correlation patterns with biopsy results. Reflex p16 immunostaining of cell blocks based on the algorithmic approach to be evaluated by a multiinstitutional comprehensive prospective study is proposed.

Two-color immunocytochemistry for evaluation of effusion fluids for metastatic adenocarcinoma.

BACKGROUND: The evaluation of serous fluids by conventional one color immunocytochemistry is complex and challenging. DESIGN: We selected and studied 37 serous fluid cytology specimens (23 pleural, 13 peritoneal, 1 pericardial), collected over a 4-year period. They were unequivocally positive for metastatic adenocarcinoma based on clinical correlation, cytomorphology, and one color immunocytochemistry on cell block sections. 3 mum serial sections of cell blocks were immunostained by a two chromogen method (peroxidase with brown chromogen followed by alkaline phosphatase with red chromogen). Combinations evaluated were: A- vimentin followed by cytokeratin (CK) 7; B- calretinin followed by BerEP4, C- calretinin followed by CK 20. Additionally, difficulty of interpretation was evaluated on a scale of 1(easy) to 5 (difficult). Cases demonstrating decreased or complete loss of immunoreactivity with alkaline phosphatase red chromogen system were also evaluated with routine one color immunostaining by alkaline phosphatase and peroxidase individually. The pretreatments for antigen retrieval and antibody dilutions were identical to those used for conventional one color immunostaining with respective immunomarker. RESULT: Combination 'A' showed correlation with the immunoreactivity pattern observed with one color immunostaining. However, the immunoreactivity of the second immunomarker was compromised in combinations B and C. In the latter group, the sections immunostained with one color alkaline phosphatase indicator system also showed weak immunoreactivity or complete loss of immunoreactivity for the corresponding second immunomarker. However, the peroxidase system showed proper immunoreactivity for those immunomarkers. Average difficulty of interpretation for the two color method was 1.06 (range- 1 to 2) as compared to 2.95 (range: 1 to 5) with the one color method. This difference was statistically significant (two-tailed P<.0001, paired t test). The higher scores of difficulty were observed in cases with a paucity of tumor cells and cases with predominance of isolated tumor cells. CONCLUSION: Dual immunostaining facilitated identification of the foreign population of malignant cells in effusion fluids with objective, reproducible precision. However, due to relatively lower sensitivity of alkaline phosphatase as a second indicator system, immunoreactivity was diminished for BerEP4 and lost for CK 20.

Preparation and using phantom lesions to practice fine needle aspiration biopsies.

Currently, health workers including residents and fellows do not have a suitable phantom model to practice the fine- needle aspiration biopsy (FNAB) procedure. In the past, we standardized a model consisting of latex glove containing fresh cattle liver for practicing FNAB. However, this model is difficult to organize and prepare on short notice, with the procurement of fresh cattle liver being the most challenging aspect. Handling of liver with contamination-related problems is also a significant draw back. In addition, the glove material leaks after a few needle passes, with resulting mess. We have established a novel simple method of embedding a small piece of sausage or banana in a commercially available silicone rubber caulk. This model allows the retention of vacuum seal and aspiration of material from the embedded specimen, resembling an actual FNAB procedure on clinical mass lesions. The aspirated material in the needle hub can be processed similar to the specimens procured during an actual FNAB procedure, facilitating additional proficiency in smear preparation and staining.

Cell block preparation from cytology specimen with predominance of individually scattered cells.

This video demonstrates Shidham's method for preparation of cell blocks from liquid based cervicovaginal cytology specimens containing individually scattered cells and small cell groups. This technique uses HistoGel (Thermo Scientific) with conventional laboratory equipment. The use of cell block sections is a valuable ancillary tool for evaluation of non-gynecologic cytology. They enable the cytopathologist to study additional morphologic specimen detail including the architecture of the lesion. Most importantly, they allow for the evaluation of ancillary studies such as immunocytochemistry, in-situ hybridization tests (FISH/CISH) and in-situ polymerase chain reaction (PCR). Traditional cell block preparation techniques have mostly been applied to non-gynecologic cytology specimens, typically for body fluid effusions and fine needle aspiration biopsies. Liquid based cervicovaginal specimens are relatively less cellular than their non-gynecologic counterparts with many individual scattered cells. Because of this, adequate cellularity within the cell block sections is difficult to achieve. In addition, the histotechnologist sectioning the block cannot visualize the level at which the cells are at the highest concentration. Therefore, it is difficult to monitor the appropriate level at which sections can be selected to be transferred to the glass slides for testing. As a result, the area of the cell block with the cells of interest may be missed, either by cutting past or not cutting deep enough. Current protocol for Shidham's method addresses these issues. Although this protocol is standardized and reported for gynecologic liquid based cytology specimens, it can also be applied to non-gynecologic specimens such as effusion fluids, FNA, brushings, cyst contents etc for improved quality of diagnostic material in cell block sections.