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Arienzo F, Valenti A, Ricci P, Ascoli V. Metastatic upper tract urothelial carcinoma with nest-like features presenting as malignant pleural effusion. Diagn Cytopathol 2024; 52:E124-E128. [PMID: 38396316 DOI: 10.1002/dc.25293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/22/2024] [Accepted: 02/15/2024] [Indexed: 02/25/2024]
Abstract
Metastatic urothelial carcinoma is a rare cause of pleural effusions. We report a case of urothelial carcinoma of the upper urinary tract in an oldest-old male patient, a smoker, with situs inversus totalis, that presented uniquely with malignant pleural effusion at presentation without evidence of a primary tumor on imaging. Cytological smears of the massive left pleural effusion revealed epithelioid neoplastic cells arranged in short cords, small-to-large clusters, and raspberry-like morules, mimicking mesothelioma; cell block preparations highlighted the presence of tubules and nest-like structures. The tumor cells showed a high nuclear-to-cytoplasmic ratio, nuclear grooves, and mitotic figures. Cytomorphologic features coupled with the immunophenotype of neoplastic cells (p63, GATA3, and uroplakin II positive) allowed the diagnosis of metastatic urothelial carcinoma and a possible nested subtype. These findings were supported by a total body computed tomography (CT) showing no evidence of a mass in the bladder or elsewhere in the urinary tract but a concentric parietal thickening of the proximal left ureter, suggesting malignancy. To our knowledge, a malignant effusion as a primary manifestation of urothelial carcinoma with nest-like features originating in the upper urinary tract has never been described previously. Our case focuses on the value of cell block in the working-up of neoplastic effusions by revealing the architectural pattern of an uncommon malignancy and the correlation between cytopathology and imaging gross findings to reach an accurate diagnosis.
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Affiliation(s)
- Francesca Arienzo
- Cytology Unit, Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Alessandra Valenti
- Emergency Radiology Unit, Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Paolo Ricci
- Emergency Radiology Unit, Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Valeria Ascoli
- Cytology Unit, Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Rome, Italy
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Michael CW. The cytologic diagnosis of mesothelioma: are we there yet? J Am Soc Cytopathol 2023; 12:89-104. [PMID: 36702736 DOI: 10.1016/j.jasc.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/01/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Mesothelioma is a rare but highly aggressive malignancy with poor prognosis that frequently present with recurrent effusions. Establishing the diagnosis by cytology can lead to early diagnosis and treatment and consequently improve prognosis. MATERIALS AND METHODS This review examines the cytological diagnosis of mesothelioma in the context of its historical and morphologic evolution and provides an update of the current reporting systems. Clues to identify the mesothelial and malignant nature of the sample are detailed as well as the supporting ancillary tests. RESULTS Cytologically, the samples are overwhelmingly cellular and malignancy is recognized by both architectural and cytological atypia. Numerous variably sized clusters and enlarged cells are easily identified, some with papillary architecture and collagen cores. Recognizing the mesothelial nature of the cells and supportive immunostains are essential to rule out the differential diagnosis of metastatic carcinomas and reactive mesothelium. Current ancillary tests such as homozygous deletion of CDKN2A, loss of BRCA1-associated protein, and methylthioadenosine phosphorylase expression can provide further support of malignancy. CONCLUSIONS At this time with the aid of current ancillary tests and in the hands of cytopathologists with adequate experience with the interpretation of effusions, the diagnosis of mesothelioma can be established with accuracy in most cases.
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Affiliation(s)
- Claire W Michael
- Department of Pathology, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, Ohio.
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Gordillo CH, Jiménez-Heffernan JA. Melamed-Wolinska bodies in a pleural effusion. Diagn Cytopathol 2022; 50:529-531. [PMID: 36040844 DOI: 10.1002/dc.25049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Carlos H Gordillo
- Department of Pathology, University Hospital La Princesa, Madrid, Spain
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Wang BG, Woodward K, Menezes G, Wang ZQ, He R, Li W. Pleural fluid metastasis of plasmacytoid urothelial carcinoma in comparison to micropapillary and conventional high-grade urothelial carcinoma: Cytologic and immuonohistochemical findings. Diagn Cytopathol 2022; 50:E248-E254. [PMID: 35560555 DOI: 10.1002/dc.24975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 04/27/2022] [Accepted: 04/29/2022] [Indexed: 11/10/2022]
Abstract
Plasmacytoid urothelial carcinoma (PUC) is a rare but clinically aggressive variant of high-grade urothelial carcinoma (HGUC). Cytological features include single plasmacytoid neoplastic cells with N:C ratio around 0.5, eccentric nuclei, nuclear hyperchromasia, irregular nuclear membrane, and vacuolated cytoplasm. Micropapillary urothelial carcinoma (MPUC) is another clinically aggressive variant of HGUC that shares some overlapping features of PUC. The diagnosis of these two aggressive variants in pleural effusions can be challenging due to features mimicking adenocarcinoma, unusual immunochemistry profile, and confusion with differential diagnoses, especially when pertinent clinical information is unavailable. We present report on one case each of pleural fluid metastasis of PUC and MPUC respectively, and compare the findings with that of a metastatic conventional HGUC originally thought to be metastatic adenocarcinoma. The diagnosis of PUC was confirmed with immunohistochemical studies showing expression for cytokeratin, GATA-3, uroplakin II, and CD138, diminished or loss of E-cadherin membranous expression, negative expression for p63, p53, Epicam-BerEP4, Epicam-MOC31, and p120. The diagnosis of MPUC was confirmed with immunostain profile similar to that of PUC except positive stain for E-cadherin, p120, and p53. The diagnosis of HGUC was confirmed with immunohistochemical studies showing expression for cytokeratin, GATA-3, uroplakin II, p63, Epicam-BerEP4 (focal weak), and Epicam-MOC31. Our cases of metastatic urothelial carcinoma showed features mimicking adenocarcinoma and others, especially the MPUC and HGUC were diagnosed without prior tissue diagnosis of urothelial carcinoma. This report emphasizes the cytohistological and immunohistochemical details of urothelial carcinoma involving effusion fluid and discusses potential pitfalls in diagnosis.
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Affiliation(s)
- Brant G Wang
- Department of Pathology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Kimberly Woodward
- Department of Pathology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Geetha Menezes
- Department of Pathology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Zoe Q Wang
- Department of Pathology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Rui He
- Department of Pathology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Wenping Li
- Department of Pathology, Inova Fairfax Hospital, Falls Church, Virginia, USA
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Mneimneh WS, Jiang Y, Harbhajanka A, Michael CW. Immunochemistry in the work-up of mesothelioma and its differential diagnosis and mimickers. Diagn Cytopathol 2021; 49:582-595. [PMID: 33675675 DOI: 10.1002/dc.24720] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 01/25/2021] [Accepted: 01/28/2021] [Indexed: 12/11/2022]
Abstract
The differential diagnosis in cellular effusions with cytological atypia often includes malignant mesothelioma (MM), reactive mesothelial proliferation, and malignancies of metastatic origin, particularly carcinomas. The International Reporting System for Serous Fluid recently established guidelines for reporting MM. In conjunction with the cytomorphologic evaluation, the role of immunochemistry (IC) was emphasized as a very useful tool in the workup of serous fluids, especially with the availability of novel markers. Utilizing a panel of markers, IC allows the characterization of the cells, whether mesothelial or not, and when mesothelial origin is established, IC can frequently assist in delineating its benign or malignant nature. IC can also confirm metastatic disease, allowing the identification of the primary origin in most cases. This review summarizes the current status of IC and its role in the diagnosis of MM and its differential diagnosis in serous fluids.
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Affiliation(s)
- Wadad S Mneimneh
- Department of Pathology, University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, Ohio, USA
| | - Yuying Jiang
- Department of Pathology, Firelands Regional Medical Center, Sandusky, Ohio, 44857, USA
| | - Aparna Harbhajanka
- Department of Pathology, University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, Ohio, USA
| | - Claire W Michael
- Department of Pathology, University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, Ohio, USA
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Diagnostic impact of ascites cytology in 941 patients: malignancy rates and time of detection in ovarian cancer relative to other tumor types. Arch Gynecol Obstet 2020; 301:1521-1532. [PMID: 32347356 DOI: 10.1007/s00404-020-05553-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 04/15/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Cytological analysis of ascitic fluid is an important tool for diagnosis, staging, and prognostic assessment in patients with cancer, but more detailed information is needed regarding malignancy rates and the time sequence in which ascites develops for different sites of cancer origin. Especially, an increased early tumor diagnosis may improve the acceptance for cytological examinations for the tumor patients in oncological practice. METHODS Ascites specimens from patients who were treated at Bayreuth Hospital from 2006 to 2015 were reevaluated retrospectively and correlated with clinical reports. RESULTS 580 of all 941 ascitis specimens (61.6%) were from patients with malignancies with predominant appearance of gastrointestinal and gynecological tumors in 516/580 (89%) patients. Histologically, 549 (94.6%) were carcinomas, 23 (4%) hematological malignancies, 5 (0.9%) mesotheliomas and 3 (0.5%) were melanomas. Malignant ascitic fluid was noted in 298 of the 580 (51.4%) patients with cancer, thus the overall malignancy rate in the ascites specimens examined was 298/941 (31.7%). The most frequent malignancy rate for gynecological tumors we obtained in ovarian cancer with 85.7% and in the upper gastrointestinal tract with 77.8% for Barrett's carcinoma and 61,4% for gastric carcinoma. Regarding time of detection, malignant ascitic fluid was noted as a separate finding, prior or simultaneous to the histological diagnosis of cancer in 225/298 patients (75.5%). An outstanding earliest occurrence was found in ovarian carcinoma in 94.9% and in the gastrointestinal tract in pancreatic carcinoma in 66.7%. CONCLUSIONS Tumor staging was the main important clinical question in our single center study of ascitic fluid, especially for patients with gastrointestinal and gynecological malignomas. The highest malignancy rate and earliest time of tumor detection caused the leading importance for ovarian tumors in malignant ascitic fluid. Moreover, the application of immunostains in our study allowed in 75.5% of all tumor patients a correct initial diagnosis, which is important for further clinical therapy.
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Hiensch R, Belete H, Rashidfarokhi M, Galperin I, Shakil F, Epelbaum O. Unusual Patterns of Thoracic Metastasis of Urinary Bladder Carcinoma. J Clin Imaging Sci 2017; 7:23. [PMID: 28584690 PMCID: PMC5450457 DOI: 10.4103/jcis.jcis_9_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 02/05/2017] [Indexed: 12/19/2022] Open
Abstract
Urinary bladder carcinoma (UBC) is the ninth most common malignancy and the second most common urological malignancy after prostate cancer in men. Thoracic metastases occur in more than half of those with muscle-invasive disease, and these generally assume the form of multiple solid parenchymal lesions characteristic of hematogenous seeding of the lung. Unusual patterns of thoracic spread of UBC have also been described albeit sporadically in the form of case reports and series. The aim of our case series is to provide illustrations of several atypical patterns of thoracic involvement by UBC such as isolated mediastinal lymphadenopathy, cavitary lung metastases, malignant pleural effusion, endobronchial disease, and pulmonary tumor embolism. This review is meant to highlight the intersection of the fields of urological oncology and thoracic radiology in the care of patients with UBC.
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Affiliation(s)
- Robert Hiensch
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York
| | - Habtamu Belete
- Division of Pulmonary and Sleep Medicine, Lenox Hill Hospital, Hofstra Northwell School of Medicine, Hofstra University, Hempstead, NY, USA
| | - Mahsan Rashidfarokhi
- Division of Pulmonary and Critical Care Medicine, Elmhurst Hospital Center, Icahn School of Medicine, Elmhurst, NY, USA
| | - Irene Galperin
- Division of Pulmonary and Sleep Medicine, Lenox Hill Hospital, Northwell Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Fouzia Shakil
- Department of Pathology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Oleg Epelbaum
- Division of Pulmonary, Critical Care, and Sleep Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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Raymond SLT, Au K, Fu R, Tauchi-Nishi PS. Metastatic genitourinary cancer diagnosed by body fluid cytology: clinicopathologic and cytomorphologic correlation. J Am Soc Cytopathol 2017; 6:48-58. [PMID: 31042634 DOI: 10.1016/j.jasc.2016.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 11/02/2016] [Accepted: 11/02/2016] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Malignant effusions secondary to genitourinary cancers constitute less than 5% of metastatic malignancies. Because of their rarity, definitive cytodiagnosis may be challenging. Our study aims to examine the incidence of malignant fluids secondary to genitourinary cancers in our institution, and to characterize their clinicopathologic and cytomorphologic features. METHODS A search of our database was undertaken for all body fluids reviewed from January 2003 through April 2014 at our institution. RESULTS During this 11.3-year study period, our search revealed 8255 body fluids. Of these, 1341 (16.2%) were malignant with only 15 (0.2%) due to a genitourinary primary, constituting a mere 1.1% of all malignant fluids. Eight cases (53%) were urothelial carcinomas, 6 (40%) were renal cell carcinomas, and 1 was a bladder leiomyosarcoma (7%). No prostate cancers were found. Seven (47%) involved the pleura, 6 (40%) were in the peritoneum, and 2 (13%) were in the cerebrospinal fluid (CSF). None were detected in the pericardium. Genitourinary metastases comprised 1.9% of peritoneal, 0.8% of pleural, 1.9% of CSF malignant fluids. CONCLUSION Metastatic genitourinary cancers in body fluids are rare, comprising only 0.2% of all fluids and 1.1% of all malignancies. The cytomorphologic features of metastatic urothelial and renal cell carcinoma, although similar to those described in the literature, are nonspecific. To our knowledge, this is the first reported case of metastatic bladder leiomyosarcoma in ascites diagnosed by effusion cytology. Because leiomyosarcoma in body fluids can demonstrate epithelioid features and cohesiveness, it may be confused with metastatic carcinomas.
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Affiliation(s)
| | - Kaylene Au
- Department of Pathology, The Queen's Medical Center, Honolulu, Hawaii
| | - Ryan Fu
- Department of Pathology, The Queen's Medical Center, Honolulu, Hawaii
| | - Pamela S Tauchi-Nishi
- Department of Pathology, University of Hawaii, Honolulu, Hawaii; Department of Pathology, The Queen's Medical Center, Honolulu, Hawaii.
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El Hag MI, Ha J, Farag R, El Hag AM, Michael CW. Utility of GATA-3 in the work-Up of breast adenocarcinoma and its differential diagnosis in serous effusions:: A Cell-Block Microarray Study. Diagn Cytopathol 2016; 44:731-6. [PMID: 27338760 DOI: 10.1002/dc.23521] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 05/26/2016] [Accepted: 06/06/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND GATA-3 is a transcription factor involved in human tissue growth and differentiation. It is a potential marker for breast carcinoma origin in metastasis and predictive of good prognosis. We aim to evaluate the role of GATA3 in determining the breast origin of metastatic adenocarcinoma in malignant effusions using immunohistochemistry on cell-block microarray in comparison with ER and PR results. METHODS Cell blocks from 100 cases of malignant and reactive serous effusions with confirmed diagnosis were selected; 28 mammary carcinomas, 64 extra-mammary adenocarcinomas (gastrointestinal, pulmonary, gynecologic), and 8 reactive mesothelium proliferation as control. Immunohistochemistry on cell-block microarray was used. Microarray slides were stained for GATA-3, ER and PR. Nuclear staining of >1% was considered positive. RESULTS GATA3, ER and PR were positive in 25 (89%), 20 (71%) and 16 (57%) of breast carcinoma cases, respectively. All non-breast cancer cases were negative for GATA-3 with the exception of one Müllerian adenocarcinoma (1.6%). The calculated sensitivity, specificity and positive predictive value (PPV) of GATA3 reactivity in determining the breast origin of metastatic adenocarcinoma was 89.3% (95% CI: 71.7-97.7%), 98.6% (95% CI: 91.6-99.9%) and 96.2% (95% CI: 80.4-99.9%), respectively. GATA3 positivity was associated with ER or PR positivity in 84% of cases. CONCLUSIONS GATA3 is a useful marker in determining the breast origin of metastatic adenocarcinoma in malignant serous effusions. Reactivity to GATA3 may indicate good prognosis. Diagn. Cytopathol. 2016;44:731-736. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Mohamed I El Hag
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical Center, 420 Delaware St SE, Minneapolis, Minnesota
| | - Jennifer Ha
- University Hospitals Case Medical Center/Case Western Reserve University, 11100 Euclid Ave, Rm 212B, Cleveland, Ohio
| | - Rosemary Farag
- University Hospitals Case Medical Center/Case Western Reserve University, 11100 Euclid Ave, Rm 212B, Cleveland, Ohio
| | - Amani M El Hag
- Cleveland Clinic Foundation, Bariatric and Metabolic Institute, 9500 Euclid Ave, Cleveland, Ohio
| | - Claire W Michael
- University Hospitals Case Medical Center/Case Western Reserve University, 11100 Euclid Ave, Rm 212B, Cleveland, Ohio
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Adhikari LJ, Elkins CT, Wakely PE. Squamous cells in effusions: A study of 24 cases. J Am Soc Cytopathol 2014; 3:21-28. [PMID: 31051726 DOI: 10.1016/j.jasc.2013.08.225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 08/06/2013] [Accepted: 08/12/2013] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Malignant squamous cells in serous effusions are rare. We present our experience with squamous cell carcinoma (SqCC) and benign squamous cells in effusions. MATERIALS AND METHODS Specimens were retrieved from our database using search codes as "squamous" within the final diagnosis under various serous effusions. RESULTS Twenty-nine specimens were recovered, and 5 of those were excluded. Of the 24 specimens, 3 were duplicates; therefore, only the first specimen from each was included for a final tally of 21 specimens. Specimens were from pleural fluid (n = 16, 76%), pericardial fluid (n = 2), pelvic fluid (n = 2), and peritoneal fluid (n = 1). Nineteen were SqCC (primary sites: 7 lung, 2 uterine cervix, 2 larynx, 2 anus, 2 esophagus, 1 tongue, 1 mandible, 1 skin, 1 vulva), and 2 patients had benign squamous cells only (1 from a ruptured esophageal adenocarcinoma and 1 from a nonmalignant esophageal rupture). In SqCC cases, a round-oval cell with dense cytoplasm was the predominant cell type (n = 12) followed by undifferentiated cells (n = 4), polygonal-type cells (n = 2), and fiber-type cells (n = 1). Of the SqCC specimens, 12 (63%) showed varying degrees of keratinization. Other features in SqCC cases included refractile rings (89%), keratin pearls (53%), and vacuolated cytoplasm (42%). Herxheimer spirals were absent. Two benign cases showed polygonal cell morphology only. All patients with SqCC died shortly after fluid collection (range 2-313 days; mean: 58.1 days). CONCLUSIONS Metastatic SqCC in serous effusions are rare, primarily arranged as single cells with rounded nuclei lacking visible nucleoli surrounded by a minimal amount of dense cytoplasm, and represent a dismal prognosis.
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Affiliation(s)
- Laura J Adhikari
- Department of Pathology, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Camille T Elkins
- Department of Pathology, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Paul E Wakely
- Department of Pathology, Wexner Medical Center at The Ohio State University, Columbus, Ohio.
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Huang CC, Michael CW. Cytomorphological features of metastatic squamous cell carcinoma in serous effusions. Cytopathology 2013; 25:112-9. [DOI: 10.1111/cyt.12065] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2013] [Indexed: 01/26/2023]
Affiliation(s)
- C. C. Huang
- Department of Pathology; University of Michigan; Ann Arbor MI USA
| | - C. W. Michael
- Department of Pathology; Case Western Reserve University/University Hospitals; Case Medical Centre; Cleveland OH USA
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