Absence of SV-40 large T antigen (Tag) in malignant mesothelioma effusions: an immunocytochemical study

Simian Virus 40 (SV 40) was recently implicated in the pathogenesis of malignant mesothelioma. The oncogenic capacity of SV-40 is a function of a nuclear protein, the large T antigen (Tag). SV-40 Tag DNA sequences are detected by the polymerase chain reaction in 40-80% of malignant mesothelial proliferations. However, the role of immunohistochemistry (IHC) in demonstrating the nuclear localization of Tag is controversial. We sought to determine the clinical utility of SV-40 Tag IHC in pleural effusion cytology as an ancillary tool in the cytologic diagnosis of malignant mesothelioma (MM). Formalin-fixed, paraffin-embedded cell block sections from 100 pleural effusions (32 MMs, 25 benign reactive, 43 metastatic adenocarcinomas) were immunostained for the SV-40 anti-Tag, using two primary monoclonal SV-40 Tag antibodies: clone Pab 416 and clone Pab 101. Despite strong and consistent immunoreactivity in positive controls, no nuclear immunostaining was observed in any case. We believe the small sample size in cytology cell block sections, the low viral copy number in infected cells, and the effect of formalin fixation may have resulted in absence of immunoreactivity. The role of SV-40 Tag IHC in diagnostic cytopathology remains unclear unless further studies reliably show its detection.

Diagnostic challenges in aspiration cytology of the salivary glands

The main goal of fine-needle aspiration (FNA) of salivary gland lesions is to assist the clinician in the management of patients who present with a mass lesion. Cytologic examination aims to determine, if a process is inflammatory and/or reactive, benign or malignant neoplasm and if possible renders a specific diagnosis. It has been argued that in the area of salivary gland tumors, surgical management relies less heavily on a specific preoperative diagnosis, because almost all neoplastic salivary gland lesions will undergo surgical excision. However, knowing beforehand if a lesion is malignant or benign, will aid in planning surgery and may prompt or postpone decisions for surgical intervention. The salivary glands are unique in their histologic complexity and morphological variability of tumors, which is reflected in the cytologic material. In addition to the overlapping morphologic patterns of salivary gland tumors, they also represent relatively rare lesions, thus making it more difficult to acquire diagnostic expertise in FNA. Other than approaching salivary gland tumors by a description of single entities in their benign and malignant categories, we favor a more practical approach to diagnosis based on the key morphologic features noted in FNAs. This article addresses differential diagnoses according to the predominant cytologic presentation with attention to the cell type and size, nature of the cytoplasm, and the smear background.

Cytodiagnosis of a meningeal fibrosarcoma metastatic to the thyroid gland

A case of primary leptomeningeal fibrosarcoma metastatic to the thyroid gland, diagnosed by fine needle aspiration biopsy is described. The patient, a 39-year-old women was initially diagnosed with a leptomeningeal fibrosarcoma. Sections of the primary tumor studied by electron microscopy showed that the tumor cells have the ultrastructure features of a fibroblast. She underwent tumor resection, followed by chemotherapy and local radiotherapy. Four months later, she presented with dysphagia. Ultrasonography confirmed the presence of a 2-cm mass in the right lobe of thyroid. A fine needle aspiration biopsy was performed. Light microscopy showed interwoven bundles of neoplastic spindle cells similar to the primary tumor, consistent with a metastatic fibrosarcoma. To our knowledge, this is the first report of a primary meningeal fibrosarcoma that metastasized to the thyroid gland, which was diagnosed by a fine needle aspiration biopsy.

Thyroid plasmacytoma mimicking medullary carcinoma: a potential pitfall in aspiration cytology

Extramedullary plasmacytoma (EMP), a malignant neoplasm of the soft tissues composed of plasma cells, may occur either as a solitary plasma-cell tumor (primary EMP) or as a manifestation of multiple myeloma (secondary EMP). We report on the aspiration cytology findings of an intriguing case of EMP of the thyroid that was initially misinterpreted as medullary carcinoma on clinical and cytologic examination. A major contributing cause for the cytologic misinterpretation was the presence of amyloid in the aspirate and the clinical impression of a "thyroid mass." Based on this experience, we suggest that EMP should be considered in the differential diagnosis of a neck mass that yields discohesive cells associated with amyloid/amyloid-like material. Clinical correlation and immunocytochemistry are crucial in avoiding pitfalls in this situation.

Immunoreactivity of ductal cells with putative myoepithelial markers: A potential pitfall in breast carcinoma

The identification of an intact layer of myoepithelial cells (MECs) located between epithelial cells and the basal lamina is useful in differentiating benign breast lesions and carcinoma in situ from invasive breast carcinoma. In the present study we used three antibodies considered to be putative markers of MECs (S100 protein, muscle-specific actin [HHF-35], and smooth muscle actin [SMA]) in 100 formalin-fixed, paraffin-embedded histologic sections of breast in an attempt to compare their value in demonstrating MECs in benign breast tissue and breast carcinomas. We concluded that for identifying MECs in benign breast tissue, SMA appears to be the most reliable, followed closely by HHF-35, but S100 is very unreliable for this purpose. In breast carcinoma, all three stains showed variable cross-reactivity with myofibroblasts, being greatest with SMA. A significant number of tumor cells in ductal carcinoma, both intraductal and invasive, stain with these markers and this "cross-reactivity" is extremely high with HHF-35. Thus, immunohistochemistry should be interpreted cautiously in differentiating benign, in situ, and invasive breast neoplasms. The "cross-reactivity" also suggests the possibility of myoepithelial differentiation and/or high actin content of breast tumor cells.

Follow-up of atypical glandular cells in cervical-endocervical smears

Atypical glandular cells of undetermined significance (AGUS) is a diagnostic category of the Bethesda system encompassing glandular-type cells that show either endometrial or endocervical differentiation and display greater atypia than expected for a reactive process but do not meet the criteria for invasive adenocarcinoma. We investigated AGUS in a follow-up study of cervical-endocervical smears with either histology or repeat cytology follow-up. From the cytology files at Northwestern Memorial Hospital over a 4-year period, 136 cervical-endocervical smears were diagnosed with AGUS, which were further subdivided into atypical glandular cells, unqualified (AGC-U); atypical glandular cells, favor reactive (AGC-FR); or atypical glandular cells, favor neoplasia (AGC-FN). Of 96 cases with either histologic or cytologic (cervical-endocervical smear) follow-up, 39 cases of AGC-U had a variety of diagnoses on follow-up, with mostly benign entities in 72% and squamous intraepithelial lesions in 28%. Follow-up of the 36 cases of AGC-FR also demonstrated mostly benign entities (82%) and five cases of squamous intraepithelial lesions. The largest number of premalignant and malignant diagnoses (48%) was found during follow-up of patients with an initial diagnosis of AGC-FN, including the only two cases of adenocarcinoma in situ in our study. In conclusion, our study confirms that AGUS encompasses a wide spectrum of diagnoses, most of which prove to be benign. Subclassification of these cases into "favor reactive" and "favor neoplasia" was found to be helpful in predicting the follow-up status of these patients. However, the small but distinctive percentage of preneoplastic and neoplastic diagnoses seen on follow-up warrant further diagnostic procedures and/or close monitoring in patients with this diagnosis.

Metaplastic breast carcinoma metastatic to the lung mimicking a primary chondroid lesion: report of a case with cytohistologic correlation

This case study illustrates the unusual morphologic findings of a metastatic breast carcinoma to the lung. The tumor showed chondromatous differentiation and mimicked a primary chondroid lesion of the lung on fine-needle aspiration and needle core biopsy. The patient was a 59-year-old woman with a previous history of stage II carcinoma of the breast, which had been reported as "poorly differentiated, infiltrating ductal carcinoma," with two of 13 axillary lymph nodes showing metastatic ductal carcinoma. The pathology report received from the outside institution contained no mention of metaplastic components, and because the new pulmonary lesion was a peripherally located, well-circumscribed mass found incidentally on abdominal computed tomography scan in the lower lung field cuts, pulmonary chondroid hamartoma was initially postulated as a preliminary diagnosis. However, on review of the outside glass slide material from a prior lumpectomy, chondromatous differentiation was identified and a final diagnosis of metaplastic carcinoma of the breast with pulmonary metastasis was made. To the best of our knowledge, this is the only reported case of a metastasis of metaplastic breast carcinoma initially identified from fine-needle aspiration biopsy. The importance of recognizing and reporting metaplastic elements in primary breast tumors is discussed, and the value of direct morphologic comparison of cytologic material to prior histology is emphasized.

Automation in cytology: a survey conducted by the New Technology Task Force, Papanicolaou Society of Cytopathology

Despite the overwhelming interest in the development of several computer based technologies in the last several years, the role of automation in cytology has remained controversial. The potential of these technologies in the reduction of false negative results in pap smears is well recognized. However, there is still remarkable confusion as how to incorporate automation in the routine practice of cytology. This prompted the New Technology Task Force of the George Papanicolaou Society of Cytopathology to design a survey to seek the opinion of those engaged in cervicovaginal cytology screening regarding the value of automation in cytology. In 1996, a ten question survey was sent to 1800 cytopathology laboratories throughout the nation. The response rate was 23% (416/1800). The responders represented laboratories varying from those with less than 5,000 pap smears to those with over 100,000 cases per year. The majority of the responders did not believe that automation is essential for cervicovaginal cytology. This was evidenced by the fact that only 12% of the laboratories were engaged in automated cytology and predominantly used it for quality control measures. The inability of small laboratories to absorb the extra expense involved in the integration of automated cytology in their practice, particularly in the current era of managed care was a major concern. There was also concern about the potential for compromise of patient care by the drive for corporate profits and the dissemination of wrong information to the public and physicians. Suggestions most frequently proposed included appropriate patient and physician education about the merits and pitfalls of the pap smear, and also endorsing an affordable universal fee for pap smears. Rescreening for all pap smears, reassessing the benefits of automation in cytology and development of the standards were other proposals. Partnership with larger cytology laboratories, creation of "cytology consortiums" with shared resources to provide regionalized automated rescreening services were also strongly suggested. This survey clearly indicates the need for further evaluation of automation in cytopathology and a focused attention to various issues surrounding cervicovaginal cytology screening.

Amiodarone pulmonary toxicity: cytopathology, ultrastructure, and immunocytochemistry

One hundred ninety cardiac patients were prospectively enrolled in an amiodarone protocol. Over a 10-year period, 16 patients developed new or progressive respiratory symptoms while taking amiodarone. These symptoms included dyspnea associated with abnormal chest radiographs or new or worsening abnormalities on pulmonary function testing. Specimens for microscopic examination were obtained by fiberoptic bronchoscopy with transbronchial lung biopsy (TBB), bronchoalveolar lavage (BAL), open lung biopsy (OLB), or autopsy. Large foamy macrophages with characteristic lamellated cytoplasmic inclusions were noted in all specimens, regardless of other evidence of pulmonary toxicity, suggesting that foamy macrophages represent a routine drug effect. Foamy macrophages were not present in BAL specimens from 53 normal controls and were rarely seen in specimens from 27 patients who had other interstitial lung diseases. When present, the foamy macrophages were less prominent than those seen in specimens from patients receiving amiodarone. Fibrosis was noted in 11 of 16 histological specimens, whereas type II-cell-hyperplasia was observed in 7 of the 16 specimens. Four of the 16 patients with respiratory symptoms died, and their autopsy revealed a combination of foamy macrophages with fibrosis and type II cell hyperplasia reflective of amiodarone pulmonary toxicity. Hyperplastic type II cells were not found in the absence of fibrosis. Immunocytochemistry allowed differentiation between foamy macrophages and type II cells and represents a useful tool for future investigations of the pathogenesis of amiodarone-induced pulmonary disease.

Intraoperative consultation in ovarian lesions: a comparison between cytology and frozen section

Little information is available on the relative value of intraoperative cytology (IOC) and frozen section (FS) in evaluation of ovarian lesions. We compared the two methods in 63 histologically proven cases of resected ovaries studied by imprints (40 cases), FNAs (38 cases), and scrapes (5 cases). Diagnoses were: 10 nonneoplastic cysts, 46 neoplasms (benign, 19; borderline, 8; and malignant, 19) and 7 tumors comprised of small blue cells (SBC): granulosa cell (3), lymphoma (1), small cell carcinoma (1), and sarcoma (2). There were no false-positive diagnoses by IOC or FS among the benign and borderline conditions. Five benign lesions, however, had FS deferred because of architectural complexity, this in contrast to only one case reported as atypical by IOC. Borderline tumors were recognized as such in 3 cases examined by FS, but no such diagnosis was possible by IOC due to the inability to assess invasion. The diagnosis in borderline neoplasms of surface epithelial origin was deferred in 4 cases by FS and reported as atypical in 5 cases examined by IOC due to the spectrum of architectural and nuclear atypia in borderline tumors. Of the 19 malignant cases, five were deferred because of uncertainty of invasion by FS, whereas two were called atypical by IOC. Five of 7 SBC tumors were recognized as such by FS and 6 of 7 by IOC, but none could be unequivocally subclassified by either method. Intraoperative FNAs and scrapes were superior to imprints, which tended to be bloodier and thicker. In contrast to FNAs, scrapes were easier to direct and yielded greater cellularity, although both methods were comparable in diagnostic accuracy. Even though the diagnostic yield of IOC was only slightly better than that of FS, it provided much better cytologic detail, and afforded a more representative sampling.

Fine-needle aspirate of primary lymphoma of bone

Primary lymphoma of bone (PLB) is a rare bone tumor. Fine-needle aspirates (FNA) were done on large destructive bone tumors from 2 elderly men, and both were initially read as inconclusive for malignancy because of scant cellularity. On retrospective study of the FNA slides after examining tissue histology, low numbers of diagnostic cells for lymphoma were recognized on the smears. There was extensive crush artifact, and most intact cells were stripped of their cytoplasm. In neither case was enough material harvested to make cell blocks or to perform special studies. Tissue histology disclosed abundant fibroconnective tissue stroma which probably made it difficult to acquire adequate FNA specimens. Another FNA done on a postoperative PLB tissue specimen disclosed similar features. Our experience in the 3 cases is consistent with the view that even though smears show scant cellularity, the diagnosis of PLB can at least be suggested by FNA. It is therefore important not to undercall the specimen because of low cellularity, and recommendation for tissue diagnosis can be given. This process is facilitated by a high index of suspicion based on clinical and radiographic findings.

Cytopathology of serous neoplasia of the ovary and the peritoneum: differential diagnosis from mesothelial proliferations

Serous neoplasia of the ovary ranges from benign adenomas through serous borderline tumors to invasive serous adenocarcinoma. This spectrum of neoplasia is at least partially reflected in the cytomorphologic features of the lesions. The objective of this study is to review the cytopathology of serous neoplasia of the ovary. In addition, cytologic features of serous surface papillary carcinoma and its distinction from peritoneal mesothelial proliferations are discussed.

Cytologic diagnosis of pseudomyxoma peritonei: common and uncommon causes

Pseudomyxoma peritonei (PP) refers to accumulation of mucus in the peritoneal cavity, regardless of cause or pathogenesis. We have reviewed 8 cases of PP diagnosed in our institution over the past 5 years. Pertinent cytologic features include a mucinous background with mesothelial cells and histiocytes. Two cases contained rare clusters of neoplastic epithelial cells, with low-grade nuclear features of malignancy. The origin and nature of the parent neoplasms were variable, with no reflection of the cytologic features of PP.

Differential diagnostic dilemmas in malignant fine-needle aspirates of liver: a practical approach to final diagnosis

We retrospectively reviewed two hundred malignant fine-needle aspirates of liver. Of these 49.5% were metastatic neoplasms, 32% were hepatocellular carcinomas, and 18.5% presented with diagnostic dilemmas. In less than half of these diagnostic challenges, differential diagnosis was between hepatocellular carcinoma and metastatic adenocarcinoma. The remainder of cases involved a variety of metastatic neoplasms. Cytomorphology in association with immunocytochemistry resolved the diagnostic problems in about half of the problematic cases. Three cases were undifferentiated and remained unclassifiable. We conclude that approximately 80% of malignant lesions of liver can be correctly diagnosed by thorough cytomorphologic analysis and good clinical correlation, and 20% pose differential diagnostic dilemmas.

Prevalence of HPV 16 and 18 DNA sequences in CIN III lesions of adults and adolescents

Adolescents may be more susceptible to cervical human papillomavirus (HPV) infections and may have more rapid progression of cervical intraepithelial neoplastic (CIN) lesions than adults. We evaluated Papanicolaou (Pap) smears and cervical tissue specimens from a consecutive series of 25 adolescent (age 15-20 yr) and 17 adult (age 35-40 yr) patients with a histologic diagnosis of CIN III. The study patients were all Detroit residents enrolled in a health maintenance organization (HMO) affiliated with Henry Ford Hospital. The cervical tissue specimens were evaluated for HPV 6b/11, HPV 16, and HPV 18 using agarose gel electrophoresis and Southern hybridization following polymerase chain reaction (PCR) DNA amplification. While the small sample size precluded testing for statistical significance, HPV 16 and/or HPV 18 DNA was detected in specimens from 21/25 (84%) adolescents compared to 12/17 (71%) adults (odds ratio [OR] = 2.2; 95% confidence interval [CI] = 0.49-9.74). The relationship between adolescence and HPV infections appears to be stronger for HPV 18 and mixed HPV 16/18 infections (OR = 5.6; 95% CI = 0.7-42.4) than for HPV 16 infections (OR = 1.93; 95% CI = 0.4-8.8). None of the cervical specimens contained HPV 6b/11 DNA. Oral contraceptive (OC) use was associated with HPV infection in patients with CIN III, but there was no association between cigarette smoking and HPV infection. The effect of OC use on the relationship of age and HPV could not be evaluated due to small sample size. The effects of previous sexually transmitted disease (STD) on the relationship of age and HPV were assessed.(ABSTRACT TRUNCATED AT 250 WORDS)

Bronchoalveolar lavage cell count and differential are not reliable indicators of amiodarone-induced pneumonitis

Amiodarone-induced interstitial pneumonitis is a serious, frequently fatal untoward effect of a commonly used antiarrhythmic agent. Recent reports suggest that bronchoalveolar lavage (BAL) fluid cellular analysis might be used to diagnose amiodarone-induced pneumonitis. The purpose of this study was to determine if the diagnosis of amiodarone-induced pneumonitis could be made by patient history, pulmonary function evaluation, and examination of BAL fluid. We studied five groups of patients. Three of the five groups received amiodarone: patients receiving amiodarone without evident lung toxic reaction, patients with amiodarone-induced pneumonitis, and amiodarone-treated patients diagnosed as having other pathologic processes involving the lung. The two other groups examined were healthy volunteers and patients with interstitial lung disease from causes other than amiodarone. Pulmonary function tests included vital capacity (FVC), first second forced exhaled volume (FEV1), total lung capacity (TLC), and diffusing capacity for carbon monoxide (DCO). BAL fluid analysis included total and differential cell counts. We found that amiodarone-induced interstitial pneumonitis was not associated with an alteration in pulmonary function or BAL cellular composition which could permit its distinction from amiodarone-treated patients diagnosed as having an unrelated pulmonary process or patients with interstitial lung disease from other causes. The most frequent abnormality encountered in patients with amiodarone toxicity was a reduction in the percentage of macrophages in the differential cell count. The sensitivity, specificity, and predictive value of this finding was 82 percent, 69 percent, and 69 percent, respectively. The sensitivity, specificity, and predictive value of a > or = 15 percent reduction in DCO was 44 percent, 50 percent, and 36 percent, respectively. We conclude that amiodarone-induced interstitial pneumonitis remains a diagnosis of exclusion, and the role of BAL fluid analysis is to narrow the differential diagnosis through microbiologic culture and cytologic examination.

Differential diagnosis between mesothelioma and adenocarcinoma: a multimodal approach based on ultrastructure and immunocytochemistry

Most compensations for asbestos-related deaths secondary to cancer center around mesothelioma and bronchogenic carcinoma. The differential diagnosis between mesothelioma and adenocarcinoma is a common and troublesome one, necessitating the correlation between clinical history, radiographic findings, and pathologic examination of tissues and cells. We describe a multimodal approach based on the use of routine and special stains, immunocytochemistry, and electron microscopy for distinguishing between mesothelioma and adenocarcinoma. Once a malignant diagnosis is arrived at by careful pathological examination, the tumor is classified as mesothelioma if mesothelial cells are identified as the constituent cells of the neoplasm. Mesothelial cells are recognized by (1) their main ultrastructural features: slender and elongated microvilli, abundant intermediate filaments, and lacking secretory granules; and (2) their characteristic immunocytochemical reactivity: positivity for cytokeratin, EMA, and vimentin, and negativity for carcinoembryonic antigen (CEA), B72-3, Leu-M1, and other gland-cell markers. A variety of methods have been attempted in an effort to distinguish between reactive and malignant mesothelial cells. In practice, however, such distinction depends more on experience and expertise than in any fool-proof ancillary tests. A number of these tests are discussed along with the illustration of classical and unusual examples of mesothelioma and other pleural tumors.

Fine-needle aspiration biopsy of pediatric neoplasms: correlation between electron microscopy and immunocytochemistry in diagnosis and classification

A series of fine-needle aspiration biopsies performed in 635 children were reviewed. The diagnoses rendered in these patients included malignant lymphoma in 139 (21.9%); Hodgkin's disease, 25 (3.9%); neuroblastoma, 58 (9.1%); Wilms' Tumor, 37 (5.8%); Ewing's sarcoma, 32 (5.0%); rhabdomyosarcoma, 25 (3.9%); retinoblastoma, 22 (3.5%); leukemia infiltrate, 33 (5.2%); and miscellaneous tumors, 52 (8.2%). In 171 patients (26.9%), the biopsy was nondiagnostic. The cytomorphological characteristics of these lesions are briefly described and illustrated. Salient morphological features are further correlated with histological and ultrastructural appearances. Immunocytochemical patterns of these tumors are also discussed briefly.

Problems encountered with the Bethesda System: the University of Iowa experience

This paper provides a descriptive summary of 1 year's experience with the Bethesda Cytologic Classification System at the University of Iowa Hospitals and Clinics. Cytotechnologists and pathologists criticized the failure of the new classification system to provide microscopic criteria for the following categories: adequacy of the smear (satisfactory, less than optimal, unsatisfactory), atypical squamous cells of undetermined significance, atypical glandular cells of undetermined significance, and inflammation-associated changes. Clinicians criticized the "less than optimal" category and the reporting of koilocytosis, moderate dysplasia, and endometrial cells. Suggestions for modifying the Bethesda System include: eliminating the less than optimal response, defining what constitutes an unsatisfactory smear, eliminating the terms low-grade and high-grade squamous intraepithelial lesion, and changing the reporting of endometrial cells.

The value of monoclonal antibody B72.3 for the diagnosis of breast carcinoma: experience with the first commercially available source

One hundred cases of invasive breast carcinoma were studied using the commercially available monoclonal antibody Anti-Human Tumor-Associated Glycoprotein-72 (MAb B72.3, Biomedical Technologies Inc, Stoughton, MA) prediluted at 8.5 micrograms/mL. Forty-three cases displayed positive reactivity with this antibody. Intensity and distribution of positive staining varied among the tumor cells. Twenty-two cases had 1% or less reactive cells, while eight cases contained 40% or more positive tumor cells. Apical cell membrane and diffuse cytoplasmic staining were present. In fifteen cases intracytoplasmic lumina and extra-cellular secretory material were highlighted by positive staining. Thirty-five cases had benign breast tissue adjacent to the tumor. Benign ductal and lobular epithelial cells were nonreactive except for two cases in which small foci of apocrine metaplasia were positive. Reactivity with MAb B72.3 was not dependent upon histologic grade, nuclear grade, nodal status, or patient age. Excluding the lower number of positively stained cases, our findings were similar to other MAb B72.3 investigations. The number of positively stained cases and the intensity of the positivity were increased by using MAb B72.3 at 5.0 micrograms/mL with overnight incubation, or by using MAb B72.3 at 40.0 micrograms/mL with 2 hours of incubation. Our findings confirm that MAb B72.3 shows reliable reactivity with breast carcinoma that is sensitive to antibody concentration and incubation time without loss of specificity for tumor cells. Our results are also consistent with the view that MAb B72.3 probably detects epithelial membrane-related antigens in breast carcinoma, as do several other antibodies.

Small cell carcinoma of the prostate

This report details clinical and pathologic aspects of a patient with small cell undifferentiated carcinoma of the prostate and systemic hyperglucagonemia. A panel of potential serologic markers was evaluated in order to document additional evidence of ectopic hormonal production. Immunocytochemical markers were sought in tissue samples from the primary neoplasm and a lung metastasis. Stains were positive for corticotropin (ACTH) and gastrin in both the prostate and in the lung, but no evidence of excess secretion was documented. These findings are consistent with the notion that neuroendocrine activity is common in undifferentiated small cell carcinomas, regardless of their site of origin.

Lipid-rich metastatic balloon-cell melanoma: diagnosis by a multimodal approach to aspiration biopsy cytology

Fine needle aspirates from one of multiple liver nodules revealed a large number of discohesive malignant cells with abundant vacuolated cytoplasm. The patient had had left eye enucleation the year before, for a melanoma with focal areas of clear cell change. Pap stained preparations from the liver FNA displayed well the nuclear features of balloon cell melanoma, including anisonucleosis, prominent nucleoli and intranuclear inclusions. Diff-Quik stain demonstrated best the cytoplasmic features such as distinct cell margins and finely dispersed and sharply delineated clear vacuoles. No pigmentation was noted but melanoma was suspected after the history prompted comparison with the enucleated specimen resected a year previously. A multimodal battery of ancillary methods including electron microscopy (EM) and immunocytochemistry (ICC) allowed the confirmation of balloon-cell melanoma, a rare variant not previously described in the eye. By EM, abundant lipids were identified along with melanin-containing structures resembling melanosomes. S-100 positivity along with negativity for epithelial, lymphohistiocyte and germ cell markers was compatible with melanoma. These findings are consistent with the view that cytologic detection of poorly cohesive, hypervacuolated cells does not exclude the possibility of melanoma. This rare example of a lipid-containing melanoma stresses the value of obtaining good clinical history, comparing FNAs to any pre-existing material and utilizing a multimodal approach to cytologic diagnosis in select cases.

Usefulness of serial pulmonary function testing as an indicator of amiodarone toxicity

A prospective study was conducted of 189 patients treated with amiodarone, maintained at doses of 400 to 800 mg/day and followed for up to 6 years. Only patients who had life-threatening ventricular arrhythmias unresponsive to conventional therapy were enrolled, and they underwent baseline pretreatment pulmonary function tests, with follow-up testing every 6 months. Morbidity and mortality statistics were confirmed by chart review and patient telephone interview. Of the 189 enrolled patients, 101 are alive, 84 are dead and 4 are lost to follow-up. Amiodarone-induced toxicity to the neurologic system, lungs, thyroid or liver was the primary or complicating cause of death in 12 of the 84 patients who died. The overall prevalence of all these forms of toxicity was 15%. Sixty-nine percent of the patients with amiodarone toxicity had pulmonary toxicity alone or combined with other forms of toxicity. Pulmonary function test abnormalities were noted at baseline in 75% of patients who had amiodarone-induced toxicity. The proportion of abnormal baseline pulmonary function tests was not significantly different among all toxic patients, pulmonary toxic patients and nontoxic patients. An evaluation of the decrease in pulmonary function over time could not distinguish patients who developed toxicity from those who did not. The observed incidence of pulmonary toxicity is consistent with published values; however, contrary to the findings of others, no statistically significant differences in pulmonary function at baseline or in changes over time were found between toxic and nontoxic patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunocytochemical evaluation of liver fine-needle aspirations

A panel of antibodies to intermediate filaments, oncofetal antigens, and hepatocellular markers was tested on a prospective series of liver fine-needle aspirates to determine its utility in distinguishing hepatocellular carcinoma (HCC) from metastatic carcinomas. All fine-needle aspirations were assisted to ensure adequate cellularity, and were examined by a multimodal approach that included the preparation of B-5-formaldehyde-fixed cell blocks by the plasmathrombin technique. alpha-Fetoprotein was positive in four of eight HCCs, including the one example of combined hepatocellular-cholangiocarcinoma, but negative in the one case of pure cholangiocarcinoma and all cases of metastatic carcinoma. Carcinoembryonic antigen positivity was noted in four HCCs, a high proportion of metastatic adenocarcinomas, and occasional metastatic squamous cell carcinomas, but not in the one example of cholangiocarcinoma. Hepatitis B surface antigen was positive in only two cases of HCCs, but not in any metastatic tumors. Keratin and vimentin were positive, respectively, in four and three HCCs, and a variable proportion of metastatic carcinomas often coexpressed both antigens. Epithelial membrane antigen was positive in five of the eight HCCs. Our findings are consistent with the view that alpha-fetoprotein and hepatitis B surface antigen are reliable markers for HCC. However, none of the immunocytochemical markers reliably distinguished the primary site of metastatic carcinoma. The intensity of the immunostains in the fine-needle aspirations was comparable with that observed in tissues, but fragmentation of cell groups interfered with interpretation. Multiple passes and verification of the cellularity of the aspirates are crucial factors for the success of this approach to diagnosis.

Rapid cytologic diagnosis of Pneumocystis: a comparison of effective techniques

There has been a dramatic increase in pneumocystis carinii pneumonia (PCP) among patients with acquired immune deficiency syndrome (AIDS) and immunosuppression. Cytologic specimens including random and induced sputum samples, bronchoscopic washings, bronchoalveolar lavage, and fine needle and open lung biopsies can all be used for a rapid, accurate, and economical PCP diagnosis. Of these, bronchoalveolar lavage has emerged as the most diagnostic specimen, but the diagnostic yield of induced sputum is under investigation. Commonly used Gomori's methenamine and Gram-Weigert silver stains identify the cyst walls. Trophozoite forms can occasionally be stained by Gram Weigert, and specifically by Giemsa and PAS techniques. Organisms occur within the alveolar secretions inspissated in the form of foamy alveolar casts (FACs). PCP can also be identified in the Papanicolaou-stained pulmonary specimens. Alveolar proteinaceous material and cyst walls are stained pale gray and the nuclei as dark dots. Pap-stained PC cysts can be excited by ultraviolet light; they fluoresce and appear greenish yellow with irregular shapes, easily distinguishable from fungi. Organisms under ultraviolet stimulation must also be distinguished from cigarette smoker's pigment, red blood cells, and mucus. Following treatment, FACs persist, GMS-stained cysts are less numerous, fluorescence diminishes, and organisms become fragmented and may appear swollen. They may be seen within the macrophages and bronchial mucus secretion. We conclude that GMS, Gram-Weigert, and routine Papanicolaou staining are valuable for rapid PCP diagnosis. Besides PCP, associated infections and cellular changes can also be correctly diagnosed in Papanicolaou-stained specimens, including other infectious and neoplastic processes common in the AIDS victim.

Ultrastructure of Pneumocystis carinii: a review of internal and surface characteristics

Electron microscopy (EM) shows unique characteristics of Pneumocystis carinii (PC) that are impossible to appreciate by light microscopy. EM's major contribution is in its elucidation of the PC life cycle, the host-parasite interaction of PC, and less so, of PC's taxonomy. Difficulty with EM stems from the propensity of PC to undergo degeneration and from the dearth of studies of well-preserved organisms. Ultrastructurally, the foamy alveolar cast (FAC) is composed of intimately associated cysts and trophozoites and contains little or no fibrin. By transmission EM (TEM), PC conglomerates are held together by slender membroanotubular extensions (MTE) growing from their concave and convex surfaces. Voids, formed by the juxtaposition of the uneven contours of the organisms and their intertwined MTE, contribute significantly to the FAC. The interior of the organisms lacks a complex organelle system typical of protozoa, but may contain intracystic bodies. Neither the MTE nor thicker processes of the cyst wall shows microtubules or any other cytoskeletal element. Trophozoites are even less rigid and adapt closely to the surface of type I alveolar epithelial cells. By scanning EM (SEM), gnome's hat-shaped organisms with beaded borders correspond to the crescent-shaped cysts noted by TEM. Slender processes are noted in rough surfaces of the organisms, whereas smooth surfaces display occasional budding. Elongated filopodia act as interparasitic fibrils but contribute little to contact with host cells. Together with argyrophilia and the Pap-stained fluorescence by UV light, the ultrastructure of PC suggests the organism is a fungus. This is in agreement with results of recent ribosomal RNA sequence studies that show PC to be related to sacharomyces.

A pathologic study of allergic bronchopulmonary aspergillosis

A lung biopsy specimen was obtained from a 10-year-old boy with cystic fibrosis and allergic bronchopulmonary aspergillosis. Light microscopy revealed a marked inflammatory process that was largely bronchocentric. Infiltrating cells included lymphocytes, plasma cells, monocytes, and numerous eosinophils. Elastin layers were intact in blood vessels and markedly disrupted in bronchioles. By immunofluorescent, major basic protein was demonstrated in eosinophils, was freely deposited outside of eosinophils, especially in the interlobular septum, and was taken up by macrophages. A number of lymphocytes stained positively for IgE. Through an immunoperoxidase stain, septate hyphae of Aspergillus were clearly observed in the lung parenchyma. A significant increase in interleukin-2 positive-staining T cells was observed with an approximate 2:1 ratio of helper to suppressor cells. The use of newer immunohistologic techniques has enabled us to gain additional insights into the pathogenesis of allergic bronchopulmonary aspergillosis.

Adenoid cystic carcinoma of the salivary glands: an immunohistochemical analysis

Adenoid cystic carcinoma is a specific variant of adenocarcinoma with a characteristic cribriform appearance. The tumor may arise from salivary glands and various other sites, but the origin and cellular composition of this unique neoplasm have been controversial. A potential use of immunohistochemistry is to provide additional information on the origin of various cellular components of tumors by comparing them with corresponding normal tissues. Immunohistochemical distributions of carcinoembryonic antigen (CEA), epithelial membrane antigen (EMA), keratin, low molecular weight keratin (54 kd), S100 protein, muscle-specific actin, laminin, and type IV collagen were evaluated in 20 adenoid cystic carcinomas arising in major and minor salivary glands. Anti-CEA, anti-EMA, anti-keratin, and anti-S100 antibodies strongly stained cells lining true lumina. Muscle-specific actin, a marker for myoepithelial cells, was found in lining cells of pseudocysts, in tumor cells proper, and in nonluminal cells with a tubular growth pattern. A monoclonal antibody against 54 kd keratin stained almost all cells in the neoplasms. In pseudocysts, replicated basal lamina reacted with antisera to laminin and to type IV collagen. The present study demonstrates that there are at least two populations of tumor cells in adenoid cystic carcinoma: luminal cells that express CEA and EMA, thus indicating their ductal character, and nonluminal cells that express muscle-specific actin characteristic of myoepithelium.

Immunocytochemistry of the thyroid in surgical and cytologic specimens

The value of immunocytochemistry in thyroid disease was evaluated in histologic and cytologic material derived from papillary carcinoma (25 cases), follicular carcinoma (nine cases), follicular adenoma (nine cases), Hürthle cell tumor (three cases), medullary carcinoma (two cases), nodular goiter (nine cases), and Hashimoto's thyroiditis (two cases). Thyroglobulin was positive in the follicular cells and/or colloid of all lesions (except medullary carcinoma) and two papillary carcinomas. Vimentin was positive in papillary carcinoma (17 of 25), follicular carcinoma (four of nine), follicular adenoma (four of nine), and nodular goiter (two of nine). Vimentin positivity, which was restricted to follicular cells, was strongest in those cells undergoing oncocytic transformation. Three markers of glandular/acinar secretory differentiation (lactoferrin, lactalbumin, and secretory component) were uniformly negative even in well differentiated follicular structures. In medullary carcinoma, both calcitonin and carcinoembryonic antigen were strongly positive in the parafollicular cells. The antibody panel can definitely identify histogenesis from the thyroid but is of little value in tumor classification. In histologic and cytologic preparations, vimentin positivity does not exclude thyroid follicular cell origin. The method can be successfully applied to richly cellular needle aspirates. This is best achieved with assisted needle aspirations when cellularity is ascertained by on-site microscopic examination of multiple passes.

Value of immunocytochemistry in the study of malignant effusions

Recognition of malignant effusion relies heavily on cytologic examination despite the difficulty of distinguishing atypical mesothelial hyperplasia from metastatic carcinoma. The combination of CEA, EMA, vimentin, keratin, high-molecular-weight cytokeratin (HMWK), low-molecular-weight cytokeratin (LMWK), and Alcian blue was tested in 51 cytologic specimens of pleural, peritoneal, and pericardial effusions. These showed metastatic carcinoma in 38 cases (ovary, 14; lung, 8; breast, 7; GI, 4; endometrium, 4; bladder, 1) and mesothelial processes in 13 (hyperplasia, 9; mesothelioma, 4). Strong positivity for EMA (92%), CEA (90%), and Alcian blue (71%) was noted in metastatic carcinoma but not in the mesothelial processes. Keratin was positive in all cases of mesothelioma but occurred also in mesothelial hyperplasias (44%) and metastatic carcinomas (47%). In mesothelial cells, HMWK was consistently stronger than LMWK, whereas in adenocarcinoma the reverse was true. There was no difference in the degree or distribution of positivity of any of the markers among the various primary sites of the neoplasms. Our findings are consistent with the view that immunocytochemistry with a battery of antibodies is useful in the recognition of malignant effusions but cannot, as yet, determine the site of origin of metastatic neoplasms.

Herpetic tracheobronchitis detected at bronchoscopy: cytologic diagnosis by the immunoperoxidase method

Herpes simplex virus (HSV) infection of the respiratory tract requires rapid specific diagnosis to avoid late complications and maximize the efficacy of available drug therapy. We report a method of accomplishing this that was tested in 33 cytologic specimens derived from sputum, washings, or brushings from 25 debilitated elderly males suffering from a variety of underlying neoplastic and nonneoplastic chronic diseases. All specimens had shown either single cells (54%), multinucleated groups (8%), or both (38%); they displayed the ground-glass appearance (86%), discrete nuclear inclusions (4%), or both (10%), as appreciated by the Papanicolaou stain. The specimens were processed by the peroxidase-antiperoxidase technique utilizing anti-HSV-1 antibody and 3,3'-diaminobenzidine (DAB) as the chromogen. In six cases, aminoethylcarbazol (AEC) was used for comparison. Twenty-nine of the 33 specimens (88%) stained positively for HSV-1 as did control sections of herpetic encephalitis and esophagitis; there were no false positives with appropriate negative controls. All 12 bronchoscopic specimens revealed virocytes with HSV immunopositivity; in contrast, 17 of 21 (80%) sputum specimens were positive for HSV. The strongest positivity was noted in bronchial brushings and washings whereas the only four negative smears were from sputum specimens. The DAB immunostain was coarser and stronger at the periphery of the cytoplasm, and the hematoxylin counterstain permitted a clear identification of nuclear viral changes. With AEC, the immunostain was more vivid and evenly distributed, but counterstaining was impaired due to the greater solubility of the chromogen. The technique is sensitive, reproducible, and less expensive and time-consuming than electron microscopy (EM) or viral cultures.

Detection of herpesvirus cervicovaginitis by a sequential Papanicolaou--immunoperoxidase technique

Herpes simplex virus (HSV) infection constitutes an immediate threat to the neonate of pregnant women who deliver vaginally, and thus requires a rapid, specific means of diagnosis that is easily applicable to cervicovaginal smears. We applied the peroxidase-antiperoxidase technique to variously fixed, previously stained Papanicolaou smears from 60 women with HSV and 18 negative controls using an HSV-2 antibody and either diaminobenzidine (DAB) or aminoethylcarbazol (AEC) as the chromogen and Mayer's, Gill's, or Lillie-Mayer's hematoxylin as the counterstain. With Papanicolaou stain alone, there was adequate cytologic demonstration of either single cells in aggregates (11%), syncytial giant cells (40%), or both (49%) that displayed a ground-glass appearance (68%), discrete nuclear inclusions (5%), or both (28%). With the peroxidase-antiperoxidase technique, 57 of the 60 HSV specimens (95%) stained moderately or strongly positive for HSV-2, as did sections of herpetic encephalitis and esophagitis. There was no false-positive staining in any of the 18 control smears revealing koilocytosis, Chlamydia, or nonspecific vaginitis. Positivity of the immunostain was more vivid and evenly dispersed through-out the cytoplasm with AEC than with DAB, but tended to wash away with alcohol-based counterstaining. In contrast, DAB was more stable, but was positive predominantly at the cell periphery and cytoplasmic processes. Lillie-Mayer's stain provided the best counterstaining for the cytologic visualization of virocytes and accompanying inflammatory and epithelial cells, which revealed a minimal degree of atypia. The fixative used had no influence on the frequency or degree of immunopositivity of virocytes, but wet fixation with 95% alcohol or Carbowax led to less background staining than Spray-Cyte.(ABSTRACT TRUNCATED AT 250 WORDS)