The role of SOX11 immunostaining in confirming the diagnosis of mantle cell lymphoma on fine-needle aspiration samples

Primary Pancreatic Lymphoma Evaluated by Fine-Needle Aspiration

OBJECTIVES

Primary pancreatic lymphoma (PPL) is rare, mimicking pancreatic ductal adenocarcinoma (PDAC) clinically and radiologically. The aim of this study is to evaluate the clinical, radiologic, and pathological characteristics of PPL diagnosed by fine-needle aspiration (FNA) in our institution.

METHODS

Patient clinical, radiologic, and pathological information was collected from the electronic health record system.

RESULTS

In total, 11 of 4,353 pancreatic FNAs met the criteria. The most common clinical symptom was jaundice, followed by abdominal pain, weight loss, and diarrhea. Abnormal laboratory findings included elevated alkaline phosphatase, total bilirubin, lactate dehydrogenase, and cancer antigen 19-9. Abnormal radiologic findings included pancreatic mass, biliary dilatation, vessel encasement, and common bile duct encasement and thickening. Five patients underwent more than 1 tissue sampling procedure before the final diagnosis of lymphoma. Final pathologic diagnosis included 7 large B-cell lymphomas and 4 follicular lymphomas. Flow cytometric analysis was performed on 9 specimens, and all demonstrated an aberrant monoclonal B-cell population.

CONCLUSIONS

PPL mimics PDAC clinically and radiologically and could be a challenge for pathologic diagnosis if lymphoma is not included in the differential diagnosis during immediate evaluation. If lymphoma is suspected during immediate evaluation, PPL could be reliably diagnosed by FNA with the aid of ancillary studies.

Serous Effusions Diagnostic Accuracy for Hematopoietic Malignancies: A Cyto-Histological Correlation

Background: The aim of this study was to establish the liability of cytological diagnostic and, along with ancillary techniques, to sub-classify hematopoietic malignancies in serous effusions.

Methods: We retrospectively reviewed the serous effusions of hematopoietic malignancies over an 11-year period, along with ancillary studies, clinical and histological data. We compared cytological along with histological diagnosis to evaluate the value of cytology itself. Furthermore, the discrepant cases were reviewed.

Results: In this study, a total of 242 cases were identified as hematopoietic malignancies. Ancillary technologies were performed: in 24 cases FCM, 242 cases ICC, 35 cases ISH, 81 cases PCR and 10 cases FISH. Cyto-histological correlation was available for 122 cases. The subtyping of hematopoietic malignancies was achieved using cytological material in 65/122 cases (53.3%). Of the 65 cases, T-Acute lymphoblastic leukemia/lymphoma (22.1%) was the leading subtype, followed by Burkitt lymphoma (5.7%), plasmacytoma (5.7%). Cyto-histological correlation showed a 100% concordant rate of diagnosis for hematopoietic malignancies and a high degree of agreement on sub-classification (51.6%). In this regard, T-acute lymphoblastic leukemia/lymphoma, plasmacytoma, extranodal NK/T-cell lymphoma, nasal type, anaplastic large cell lymphoma, myeloid sarcoma, and follicular lymphoma showed the highest degree of agreement (100%). The sub-classification on cytology was achieved in 53 out of the remaining 120 cases without histological diagnosis (44.2%). T-acute lymphoblastic leukemia/lymphoma (20.8%) was again the most frequently encountered subtype, followed by plasmacytoma (5.8%) and Burkitt lymphoma (4.2%).

Conclusions: This large series study provided evidence that combining cytology and ancillary studies enabled the accurate serous effusions cytological diagnoses and subsequent sub-classification for the described malignancies.

A Proposal for the Performance, Classification, and Reporting of Lymph Node Fine-Needle Aspiration Cytopathology: The Sydney System

BACKGROUND

The evaluation of lymph nodes (LN) by fine-needle aspiration cytology (FNAC) is routinely used in many institutions but it is not uniformly accepted mainly because of the lack of guidelines and a cytopathological diagnostic classification. A committee of cytopathologists has developed a system of performance, classification, and reporting for LN-FNAC.

METHODS

The committee members prepared a document that has circulated among them five times; the final text has been approved by all the participants. It is based on a review of the international literature and on the expertise of the members. The system integrates clinical and imaging data with cytopathological features and ancillary techniques. The project has received the endorsement and patronage of the International Academy of Cytology and the European Federation of the Cytology Societies.

RESULTS

Clinical, imaging, and serological data of lymphadenopathies, indications for LN-FNAC, technical procedures, and ancillary techniques are evaluated with specific recommendations. The reporting system includes two diagnostic levels. The first should provide basic diagnostic information and includes five categories: inadequate/insufficient, benign, atypical lymphoid cells of undetermined/uncertain significance, suspicious, and malignant. For each category, specific recommendations are provided. The second diagnostic level, when achievable, should produce the identification of specific benign or malignant entities and additional information by utilizing ancillary testing.

CONCLUSION

The authors believe that the introduction of this system for performing and reporting LN-FNAC may improve the quality of the procedure, the report, and the communication between cytopathologists and the clinicians. This system may lead to a greater acceptance and utilization of LN-FNAC and to a better interdisciplinary understanding of the results of this procedure.

Diagnostic accuracy of SOX11 immunohistochemistry in mantle cell lymphoma: A meta-analysis

SOX11 is a transcription factor that is normally expressed in the fetal brain and has also been detected in some malignant tumors, including mantle cell lymphoma (MCL). MCL is a mature B-cell lymphoma that characteristically expresses cyclin D1, which has been used as a diagnostic tumor marker. SOX11 has also recently emerged as a tumor marker for MCL, particularly in cyclin D1-negative MCLs and to distinguish between MCLs and other cyclin D1-positive lymphomas. In this study, we evaluated the diagnostic accuracy of SOX11 immunohistochemistry for the diagnosis of MCL using a meta-analysis. A comprehensive literature search was performed using the PubMED, EMBASE, and Cochrane library through May 9, 2018. In total, 14 studies were included in our meta-analysis. The sensitivity, specificity, and area under the curve calculated from the summary receiver operator characteristic were 0.9, 0.95, and 0.934, respectively. Effect sizes of log positive likelihood ratios, log negative likelihood ratios, and log diagnostic odds ratios were 2.67, -2.12, and 5.27, respectively. Statistically significant substantial heterogeneity was observed for specificity (I2 = 95%), but not for sensitivity. Subgroup analysis and meta-regression were performed to explain the heterogeneity in specificity and showed that the proportions of Burkitt's lymphoma, lymphoblastic lymphoma, and hairy cell leukemia were significant covariates among studies using rabbit polyclonal antibodies. Overall, this meta-analysis showed that SOX11 was a useful diagnostic marker for MCL, with the clone MRQ-58 mouse monoclonal antibody showing particularly robust performance.

Utility of NKX3.1 Immunostaining in the Detection of Metastatic Prostatic Carcinoma on Fine-Needle Aspiration Smears

OBJECTIVES

NK3 homeobox 1 (NKX3.1) has been increasingly used to diagnose metastatic prostatic carcinoma in histologic samples. However, its utility and reliability in cytologic direct smears have not been studied.

METHODS

A total of 59 fine-needle aspiration (FNA) cases with a definitive diagnosis of metastatic carcinoma from the prostate were included. The cases were grouped based on different Gleason score in their corresponding primary tumors and morphologic variants. For each case, tumor cells were immunostained with NKX3.1, prostate-specific antigen (PSA), and prostatic acid phosphatase (PAP) on cell-transferred smears.

RESULTS

NKX3.1 was strongly and diffusely positive in all 40 metastatic prostatic adenocarcinomas, including those with ductal features, but negative for the 19 small cell carcinoma (SmCC) cases. NKX3.1 had a better detection rate than PSA (13/50, 26%) and PAP (0/47, 0%).

CONCLUSIONS

NKX3.1 immunostaining on FNA smears is highly reliable for detecting metastatic prostatic carcinomas of conventional and ductal types but not for SmCC.

Lymph node fine-needle cytology in the era of personalised medicine. Is there a role?

The 2016 World Health Organisation revised classification of lymphoma has sub-classified well-defined entities and added a number of provisional entities on the basis of new knowledge on genetic, epigenetics and phenotypical data; prognostic and predictive features are also part of this classification. New knowledge on well-defined entities further enlightens the mechanisms of lymphomagenesis, which are more complex and multifactorial than once believed. Therapies are also more complex because traditional clinical trials have been integrated with new drugs and compounds with unique mechanisms of actions against distinct molecular targets. As lymphoma acquires additional genetic and phenotypic features over the time, pathological assessment is also necessary. Histological evaluation and tissue collection by surgical biopsies are necessary for phenotypical and molecular purposes; however, these are demanding procedures for both the patient and the health care system. At the same time, the choice of the best treatment for a specific entity, in different phases and different patients requires information that may not be available when the biopsy is performed. Fine needle aspiration cytology (FNAC) is successfully used in lymph nodes (LNs) in combination with different ancillary techniques and might be used to assess the phenotypic and genetic profile of specific targets and to get key information for therapy, in different phases and stages of the disease, with the option to re-check the same target over time, without surgical excision. This brief review describes LN-FNAC diagnostic criteria, current therapies for lymphomas and the potential role of LN-FNAC in selecting non-Hodgkin lymphomas patients for specific targeted treatments.

Magnifying glass on spiradenoma and cylindroma histogenesis and tumorigenesis using systematic transcriptome analysis

Spiradenoma and cylindroma are related sweat gland tumors. To delineate their histogenesis, gene profiles, and their potential drivers, we performed a whole-transcriptome sequencing analysis of fourteen samples of spiradenoma/cylindroma in comparison to normal samples. A total of 12 spiradenomas, 5 cylindromas, 3 hybrid spiradenomas/cylindromas and 2 adnexal carcinomas were included in this study. 1335 characteristic genes and transcripts expressed over all 14 spiradenoma/cylindroma tumors were identified, and two groups of expression profiles were observed. Highest upregulated top 7 gene signatures characterized benign tumors with developmental and differentiation related genes, and carcinomas with top 7 genes mainly related to signaling, reorganization and metabolism of membranes. Immunohistochemistry of protein expressions validated 4 upregulated genes (ODAM, HOXB13, MYB and SOX10) considered important and as potential biomarkers for spiradenomas and cylindromas. We further compared the transcriptome of eccrine adnexal tumors with the transcriptome of adenoid cystic carcinoma (ACC) to identify the overlapping genes that may indicate histogenesis. There were 36 specific genes overlapping between adnexal carcinomas and the epithelial-dominant subtype of ACC, and 27 specific genes overlapping benign adnexal tumors with the myoepithelial-dominant subtype of ACC, At this point there is no known specific biomarker to aid in the diagnosis of eccrine spiradenoma and cylindroma in small samples or biopsies within the context of morphological overlap with ACC. In conclusion, spiradenomas and cylindromas are characterized by overexpressed developmental genes, where LHX2 and activated WNT signaling possibly drive associated carcinomas.

Cytologic perspectives on neoteric B-cell lymphoproliferative disorders

The 2008 World Health Organization (WHO) classification of hematopoietic and lymphoid tissues has been recently revised, and publication of the updated 2016 version is expected soon. Given that cytopathologists are often involved in the diagnosis of primary, recurrent, and transformed lymphoproliferative disorders, knowledge of updates to the WHO lymphoma classification, including terminology, pathogenesis, ancillary techniques, and targeted therapies is necessary. Herein, we reference the last decade of cytology specific literature for seven newer B-cell disorders and provide illustrative examples of each entity from our files.

Utility and pitfalls of GATA3 immunocytochemistry for diagnosis of metastatic breast carcinoma and urothelial carcinoma on cytology specimens

INTRODUCTION

Although GATA3 expression has been studied extensively on histology specimens and has demonstrated a high level of accuracy in detecting carcinomas from breast or urothelial origin, its utility on cytology samples, especially the influence of different sample (fine-needle aspiration [FNA] versus effusion fluid) and preparation (cell block versus smear) on the staining, is understudied.

MATERIALS AND METHODS

We retrospectively searched our institution's pathology database for cytologic cases where GATA3 immunostaining was performed during diagnostic workup and identified a total of 178 cases, consisting of 89 metastatic breast carcinomas, 22 metastatic urothelial carcinomas, and 67 malignant neoplasms of other origin. Frequency of GATA3 expression was evaluated in each group.

RESULTS

For metastatic breast carcinomas, 75% expressed GATA3; 74% on FNA samples and 77% on fluid samples; 71% on cell block and 89% on smear. GATA3 was positive in 44% triple-negative breast carcinomas. Of the 22 metastatic urothelial carcinomas (21 FNA samples and 1 fluid; 21 cell blocks and 1 smear), all were positive for GATA3. Of the 67 malignancies of other origin, 4 (6%) were positive for GATA3 (ie, a metastatic ovarian serous carcinoma, a metastatic squamous cell carcinoma, a recurrent poorly differentiated skin adnexal carcinoma, and a metastatic thymic carcinoma).

CONCLUSIONS

GATA3 is a useful biomarker for detecting carcinomas of breast or urothelial origin on cytologic specimens. It may detect breast cancers with the triple-negative phenotype. Both cell block and smear preparations can be reliably used for the staining. GATA3-positive immunostaining is occasionally seen in other tumors, which may cause diagnostic confusion.

SOX11 is a biomarker for cyclin D1-negative mantle cell lymphoma

Cyclin D1 (CCND1) protein overexpression and/or the t(11;14)(q13;q32) translocation are the pathognomonic hallmarks of mantle cell lymphoma (MCL). However, there have been cases that lacked both t(11;14) and cyclin D1 protein but still had a gene expression profile suggesting a diagnosis of MCL. SOX11 expression was detected in most cyclin D1- negative MCL and can serve as a specific biomarker for the diagnosis of this subset of MCL. Lack of SOX11 expression in MCL was associated with an indolent subset and favorable prognosis.

Plasma cell and terminal B-cell differentiation in mantle cell lymphoma mainly occur in the SOX11-negative subtype

Mantle cell lymphoma is a mature lymphoid neoplasm characterized by the t(11;14)(q13;q32) and cyclin D1 overexpression. SOX11 is a transcription factor commonly overexpressed in these tumors but absent in most other mature B-cell lymphomas whose function is not well understood. Experimental studies have shown that silencing of SOX11 in mantle cell lymphoma cells promotes the shift from a mature B cell into an early plasmacytic differentiation phenotype, suggesting that SOX11 may contribute to tumor development by blocking the B-cell differentiation program. The relationship between SOX11 expression and terminal B-cell differentiation in primary mantle cell lymphoma and its relationship to the plasmacytic differentiation observed in occasional cases is not known. In this study we have investigated the terminal B-cell differentiation phenotype in 60 mantle cell lymphomas, 41 SOX11-positive and 19 SOX11-negative. Monotypic plasma cells and lymphoid cells with plasmacytic differentiation expressing cyclin D1 were observed in 7 (37%) SOX11-negative but in none of 41 SOX11-positive mantle cell lymphomas (P<0.001). Intense cytoplasmic expression of a restricted immunoglobulin light chain was significantly more frequent in SOX11-negative than -positive tumors (58 vs 13%) (P=0.001). Similarly, BLIMP1 and XBP1 expression was also significantly more frequent in SOX11-negative than in -positive cases (83 vs 34% and 75 vs 11%, respectively) (P=0.001). However, no differences in the expression of IRF4/MUM1 were observed among these subtypes of mantle cell lymphoma. In conclusion, these results indicate that SOX11-negative mantle cell lymphoma may be a particular subtype of this tumor characterized by more frequent morphological and immunophenotypic terminal B-cell differentiation features that may be facilitated by the absence of SOX11 transcription factor.

Mantle cell lymphoma: a report of 31 nodal and extranodal fine-needle aspirates

INTRODUCTION

This study reports our experience using aspiration cytopathology coupled with various auxiliary tests in achieving diagnostic accuracy in cases of mantle cell lymphoma (MtCL) from both nodal and extranodal sites.

MATERIALS AND METHODS

Specimens retrieved from our cytology database used search codes for MtCL. Tissue files were searched for any cases of MtCL that had corresponding fine-needle aspiration biopsy (FNAB) cytopathology. FNAB was performed using the standard technique.

RESULTS

Thirty-one aspirates of MtCL were recovered: 11 primary and 20 recurrent examples over a wide age range (x = 63 years). All had histologic confirmation. Nearly one-half were from extranodal sites (14; 45%), mostly representing skin/soft tissue masses. Microscopic examination showed a monotonous proliferation of small-medium lymphocytes in a dispersed pattern with dendritic cells and rarely tingible-body macrophages. Flow cytometry (FCM) performed on all but 6 aspirates demonstrated light chain clonality. In 12 aspirates, ancillary testing in addition to FCM consisted of fluorescence in situ hybridization only (6 cases), fluorescence in situ hybridization plus immunohistochemical (IHC) (2), and IHC only (4). One case had cell block IHC alone without FCM. A specific diagnosis of MtCL was made from 45% of primary and 89% of recurrent MtCL cases. No examples of a correct, specific FNAB diagnosis of MtCL were made without the use of some form of auxiliary testing.

CONCLUSIONS

Aspirates of MtCL are characterized by nonspecific relatively uniform small-sized to medium-sized lymphocytes. A specific diagnosis of MtCL is achievable in nodal/extranodal sites, but only when a combination of auxiliary studies is judiciously employed.