Touch prep (TP) cytology as a tool for determining pulmonary parenchymal resection margin status

18095

Background: Accurate determination of parenchymal resection margins is critical in excision of primary and metastatic lung cancers. Complete microscopic examination of the entire margin is difficult and may not give timely results. Staple-line excision may compromise the accuracy of histologic margin exam (HME). TP offers a novel method to obtain pulmonary parenchymal margin status intraoperatively. Methods: Patients undergoing wedge resection for a known malignant lung lesion were studied prospectively. At the time of resection, the specimen stapled margin underwent TP on 3 glass slides for cytological analysis. The presence or absence of malignant cells on TP was correlated to final HME. Local recurrence and overall survival by TP and HME status were compared using logrank test. Results: Thirty specimens from 29 patients were studied between December 2002 and April 2006. Fifteen specimens (50%) were right- sided; 9/29 patients (31%) were male. Median age was 66 years (range 28 - 81). Histologies included non-small cell lung cancer (NSCLC) in 22 (73%), and metastases from colorectal cancer (4/30, 13%), sarcoma (2/20, 7%), and breast (1/30, 3%). All TP negative specimens had negative HME. TP was positive in 10 of 30 (33%) specimens, 6 of which had negative HME. These included 4 NSCLC and metastases from sarcoma (1) and colon (1). Mean margin distance was 4 ± 1.7 mm for TP/HME negative specimens, 0.5 ± 0 mm for TP/HME positive specimens, and 5 ± 1.7 mm for TP positive/HME negative patients. There was no difference in time to local recurrence between patients with positive margins by TP vs HME (18.6 and 18.63 months), or in TP and HME negative patients (30.1 and 30.6 months). Conclusion: TP analysis of lung parenchymal margins is safe and feasible. A negative TP is highly predictive of negative HME. Factors contributing to false-positive TP remain unresolved. Multi-institutional prospective studies are indicated for further characterization of this promising tool.

No significant financial relationships to disclose.

Nipple aspirate cytology and pathologic parameters predict residual cancer and nodal involvement after excisional breast biopsy

We previously demonstrated that abnormal nipple aspirate fluid (NAF) cytology predicted residual breast cancer (RC) and tumour size after excisional biopsy (EB), although normal NAF cytology did not exclude RC. Tumour size correlates with the risk of lymph node (LN) metastases. LN metastases provide prognostic information allowing medical and radiation oncologists to determine the need for adjuvant therapy. We hypothesized that pathologic factors known after EB, combined with NAF cytology, would predict with a high degree of accuracy the presence of RC and LN spread. NAF cytology and pathologic parameters: tumour distance from biopsy margins, multifocal and multicentric disease, sub-type of ductal carcinoma in situ (DCIS) or invasive cancer (IC), grade of DCIS or IC, tumour and specimen size, tumour and biopsy cavity location, presence or absence of extensive DCIS, and biopsy scar distance from the nipple were evaluated bivariately and then by logistic regression (LR) for their association with RC and involved LN (> or = 1 (+) LN, useful to determine chemotherapy need, and > or = 4 (+) LN, useful to determine radiation need to the chest and axilla). Data were analysed using NAF cytology alone, pathologic parameters alone, and NAF cytology and pathologic parameters combined. The combined LR model was superior in predicting residual cancer (94%) to LR models using NAF cytology (36%) or pathologic parameters (75%) alone. When only subjects with normal NAF cytology were evaluated by LR, the model was 92% sensitive in predicting RC. Tumour size and NAF cytology predicted which patients had > or = 1 (+) LN, whereas tumour and specimen size predicted which patients had > or = 4 (+) LN. We propose an algorithm which, if confirmed in a larger study, may allow clinicians to be more selective in their recommendations of re-excision breast biopsy or mastectomy.

Extramedullary plasmacytoma confined to the choroid

PURPOSE

To report a case of an extramedullary plasmacytoma confined to the choroid.

METHODS

Interventional case report with cytopathologic correlation.

RESULTS

A 76-year-old asymptomatic woman presented with 2 globular orange and amelanotic choroidal lesions in the right eye. Fine needle aspiration biopsy of one of the choroidal lesions followed by immunocytochemical studies revealed monoclonal plasma cells, diagnostic of plasmacytoma. Systemic evaluation was negative, except for increased serum gamma globulin with immunoglobulin kappa spike on electrophoresis. The patient was managed by ocular external beam radiotherapy. At 9 years follow-up, she was free of local disease and never developed multiple myeloma.

CONCLUSION

Extramedullary plasmacytoma confined to the choroid is rare. It may present simulating other common amelanotic choroidal lesions. Fine needle aspiration biopsy and proper systemic evaluation are critical in establishing the diagnosis.

Differentiating large cell lymphoma from indolent small B-cell lymphoma in fine needle aspirates using p53, PCNA and transformed lymphocyte count

OBJECTIVE

To determine the usefulness of proliferating cell nuclear antigen (PCNA), p53 protein expression and transformed lymphocyte count (TLC) as adjunctive tests to differentiate indolent small B-cell lymphoma from large cell lymphoma in fine needle aspiration biopsies.

STUDY DESIGN

Aspirates of lymphoproliferative disorders from April 1993 to January 1997 were reviewed. The percentage of TLCs was determined on the Papanicolaou smear. The percentage and intensity of p53 and PCNA immunocytochemical staining was evaluated on cell block sections. These results were compared and correlated with the final diagnoses based on available morphology, flow cytometry and clinical history.

RESULTS

There were 40 cases of non-Hodgkin's lymphoma and 12 reactive lymph nodes. Adequate cell blocks were available on 16 large cell lymphomas, 7 grade 1-2 follicular center cell lymphomas, 6 mucosal associated lymphoid tissue lymphomas, 2 small lymphocytic lymphomas and 2 mantle cell lymphomas. Average TLC and p53 nuclear staining was highest in large cell lymphomas (57% TLC and 24% p53), followed by grades 1 and 2 follicular lymphomas (14% TLC and 15% p53) and lowest in other indolent lymphomas (< 10% TLC and < 1% p53). Average PCNA staining was highest in large cell lymphomas (46%) and lowest in small lymphocytic lymphomas (7%); however, TLC was the best parameter for differentiating large cell lymphoma from indolent small B-cell lymphoma.

CONCLUSION

TLC differentiated large cell lymphoma from indolent small B-cell lymphoma better than either p53 or PCNA alone or in combination. Significant overlap between categories limits usefulness of these immunocytochemical stains for differentiating these entities.

Choroidal metastasis as the initial manifestation of a pigmented neuroendocrine tumor

We report the case of a 77-year-old woman in whom choroidal metastasis was the initial manifestation of a primary neoplasm presumed to be a pigmented pulmonary carcinoid tumor. The tumor initially was misdiagnosed cytologically and pathologically as a choroidal melanoma because it contained intrinsic melanin pigment. Positive immunoreactivity for cytokeratin, synaptophysin, chromogranin, and calcitonin and the presence of dense-core neurosecretory vesicles disclosed by electron microscopy established that the metastasis was a neuroendocrine tumor. Findings from systemic evaluation suggested that the primary tumor was located in the lung. The patient subsequently developed an intradural paraspinal metastasis, which also contained melanin pigment. The latter observation confirmed that the melanin in the uveal metastasis was intrinsic and did not represent secondary phagocytosis by tumor cells. Metastases from pigmented tumors of nonmelanocytic derivation are exceedingly rare but present a major diagnostic challenge to ocular pathologists and cytopathologists if the diagnosis is not suspected. Confirmatory immunohistochemical analysis should be obtained when a pigmented choroidal tumor thought to be a melanoma has atypical features. Arch Ophthalmol. 2000;118:841-845

Differential distribution of the neuron-associated class III beta-tubulin in neuroendocrine lung tumors

OBJECTIVE

To study the immunoreactivity profile of the neuron-associated class III beta-tubulin isotype (beta III) in epithelial lung tumors.

DESIGN

One hundred four formalin-fixed, paraffin-embedded primary and metastatic lung cancer specimens were immunostained with an anti-beta III mouse monoclonal antibody (TuJ1) and an anti-beta III affinity-purified rabbit antiserum. Paraffin sections from fetal, infantile, and adult nonneoplastic lung tissues were also examined.

RESULTS

In the fetal airway epithelium, beta III staining is detected transiently in rare Kulchitsky-like cells from lung tissues corresponding to the pseudoglandular and canalicular but not the saccular or alveolar stages of development. beta III is absent in healthy, hyperplastic, metaplastic, and dysplastic airway epithelium of the adult lung. In contrast, beta III is highly expressed in small cell lung cancer, large cell neuroendocrine carcinoma, and in some non-small cell lung cancers, particularly adenocarcinomas. There is no correlation between expression of beta III and generic neuroendocrine markers, such as chromogranin A and/or synaptophysin, in pulmonary adenocarcinomas. Also, focal beta III staining is present in primary and metastatic adenocarcinomas (to the lung) originating in the colon, prostate, and ovary. beta III is expressed to a much lesser extent in atypical carcinoids and is rarely detectable in typical carcinoids and squamous cell carcinomas of the lung. The distribution of beta III in small cell lung cancer and adenocarcinoma metastases to regional lymph nodes and brain approaches 100% of tumor cells, which is substantially greater than in the primary tumors.

CONCLUSIONS

In the context of neuroendocrine lung tumors, beta III immunoreactivity is a molecular signature of high-grade malignant neoplasms (small cell lung cancer and large cell neuroendocrine carcinoma) although its importance in atypical carcinoids must be evaluated further. In addition, beta III may be a useful diagnostic marker in distinguishing between small cell lung cancers and certain non-small cell lung cancers (poorly differentiated squamous cell carcinomas), especially in small biopsy specimens. To our knowledge, beta III is the only tumor biomarker that exhibits a substantially more widespread distribution in poorly differentiated than in better differentiated pulmonary neuroendocrine tumors. However, the significance of beta III phenotypes in non-small cell lung cancer, particularly adenocarcinoma, with respect to neuroendocrine differentiation and prognostic value, requires further evaluation.

Biological markers of risk in nipple aspirate fluid are associated with residual cancer and tumour size

We previously demonstrated that nipple aspirate fluid (NAF) can be obtained from virtually all non-Asian women between the ages of 30 and 72. The focus of this report is to (1) determine the association of candidate markers of breast cancer risk in NAF obtained from fresh mastectomy specimens with residual breast carcinoma, and (2) evaluate the association of the markers with breast tumour progression. Nipple aspiration was performed on 97 specimens. Cytology, DNA index (including % hypertetraploid cells), cell cycle parameters (S phase fraction, % cells in G2/M), prostate-specific antigen (PSA), epidermal growth factor (EGF), testosterone, carcinoembryonic antigen (CEA) and prostaglandin D synthase (PGDS) were evaluated in NAF for their association with (1) residual ductal carcinoma in situ (DCIS) or invasive cancer, and (2) pathologic tumour size. NAF was obtained from 99% (96/97) of specimens. Atypical and malignant NAF cytology were significantly associated with residual DCIS or invasive cancer (P = 0.001) and with larger tumours (P = 0.004). One hundred per cent and 88% of subjects with malignant and atypical NAF cytology, respectively, had residual carcinoma. The percentage of cells in G2/M and DNA index were associated both with risk of residual carcinoma (P = 0.01 for each) and larger tumour size (DNA index, P = 0.03; G2/M, P = 0.05), although neither biomarker improved the ability of NAF cytology, to predict residual breast cancer. Higher DNA index was associated with atypical cytology (P = 0.0001). In summary, atypical and malignant NAF cytology are associated with larger tumour size, and are highly predictive of residual carcinoma after needle or excisional biopsy of the breast.

Utilization of fine-needle aspiration cytology and flow cytometry in the diagnosis and subclassification of primary and recurrent lymphoma

BACKGROUND

The primary diagnosis of non-Hodgkin's lymphoma/leukemia (NHL) by fine-needle aspiration (FNA) is controversial. The authors reviewed their experience with FNA and flow cytometry (FC) to determine the usefulness and limitations of these techniques in the diagnosis of NHL.

METHODS

Slides and reports from all lymph node and extranodal FNAs performed during the period July 1993 to January 1997 with a diagnosis of lymphoma or benign lymphoid process were reviewed. Clinical and biopsy follow-up data were recorded. Results were tabulated and the usefulness of cytology was analyzed.

RESULTS

There were 100 adequate aspirates from 87 patients. These included 72 cases of NHL, 58 (80%) of which were diagnosed by FNA and FC without the need for histologic sampling (69% of the primary lymphomas and 88% of the recurrent lymphomas). There were 22 aspirates suspicious for lymphoma, 12 equivocal results, and 7 benign diagnoses. Eighty-six percent of malignant FNAs (50 of 58) had flow cytometry (FC) as compared with only 15% (5 of 34) of the suspicious or equivocal FNAs.

CONCLUSIONS

FNA is a valuable method for diagnosing and subclassifying NHL, although immunophenotyping by FC is often an essential ancillary test. In our experience, correlating the FNA results with the FC results can eliminate the need for a more invasive surgical biopsy in many cases.

Cellular distribution of retinoic acid receptor-alpha protein in serous adenocarcinomas of ovarian, tubal, and peritoneal origin: comparison with estrogen receptor status

Retinoids are effective growth modulators of human ovarian carcinoma cell lines. Their effects are mediated by nuclear retinoic acid receptors (RARs) and retinoid X receptors (RXRs), which are transcriptional factors and members of the steroid/thyroid receptor superfamily. To our knowledge, until now, the cellular distribution of RAR proteins in human ovarian tumor specimens is unknown. This study provides new data on the differential cellular localization of RAR alpha protein in 16 serous adenocarcinomas originating from the ovaries, fallopian tubes, and the peritoneum. Using an affinity-purified antiserum specific for RAR alpha and a monoclonal antibody recognizing the full-length estrogen receptor molecule (clone 6F11), we performed immunohistochemistry on frozen tissue sections and examined the relationship between RAR alpha and estrogen receptor protein expression by comparing the percentage of immunostained tumor cells for either receptor. Our findings indicate a strong linear relationship between the percentages of RAR alpha- and estrogen receptor-labeled tumor cells as determined by linear regression analysis (P < 0.005, r = 0.825). A modest inverse relationship was found between the percentage of RAR alpha-positive tumor cells and histological grade, attesting to a differentiation-dependent trend (P < 0.04). No significant relationship was found between RAR alpha-labeled cells and clinical stage (P = 0.139), site of tumor origin (ovaries versus fallopian tubes versus peritoneum) (P = 0.170), and primary versus metastatic lesion (P = 0.561). Thus, serous adenocarcinomas are capable of expressing RAR alpha and estrogen receptor despite high histological grade and advanced stage of neoplastic disease. Compared with the heterogeneous localization of RAR alpha in cancer cells, there was widespread RAR alpha immunoreactivity in tumor-infiltrating lymphocytes, vascular endothelial cells, and stromal fibroblasts, underscoring the value of immunohistochemistry in the accurate determination of RAR/(RXR) content in tumor specimens.

Prostate-specific antigen production in the female breast: association with progesterone

Prostate-specific antigen (PSA) is produced by the female breast. Prior in vitro evidence suggests that PSA expression in breast epithelial cells is regulated by androgens and progestins but not estrogens. The purpose of this study was to determine whether (a) PSA expression in breast nipple aspirate fluid (NAF) and in serum is influenced by progesterone (PG); (b) the ability to obtain NAF decreases with repeated breast aspirations; and (c) PSA in NAF correlates with abnormal NAF cytology. Eight pre- and three postmenopausal women with no breast cancer risk factors were enrolled in a pilot study and had NAF and serum collected every 3-4 days for a month to evaluate the influence of serum PG, luteinizing hormone, estradiol, and follicle-stimulating hormone on PSA in serum and in NAF. NAF was obtained in 99% (112 of 113) of aspiration visits. Median, mean, and peak NAF but not serum PSA levels were higher in pre- than in postmenopausal subjects. NAF PSA levels were associated with the rise or peak in serum PG in seven of eight premenopausal women (seven of seven with a PG surge) and in zero of three postmenopausal women. Considering all 11 women, there was an association between NAF PSA and PG (P = 0.005) but not luteinizing hormone, estradiol, or follicle-stimulating hormone. NAF volume did not significantly change over time. Atypical hyperplasia (9%) and hyperplasia without atypia (36%) were identified in the NAF of a subset of the subjects. Median, mean, and peak levels of NAF PSA (P = 0.05, 0.05, and 0.10, respectively) were higher in subjects with normal versus hyperplastic cytology. PSA production in the breast increases in association with PG. With aspiration every 3-4 days, NAF volume does not significantly decrease over time. NAF cytology and PSA levels in NAF may help identify women at increased breast cancer risk. Changes in biomarkers of breast cancer risk in NAF (including PSA and cytology) may predate mammographic abnormalities. NAF may, therefore, be useful as a breast cancer screening tool for young women who are not recommended to undergo mammography and as an adjunct to screen women who have mammograms performed.

The value of transformed lymphocyte count in subclassification of non-Hodgkin's lymphoma by fine-needle aspiration

No established criteria exist for predicting lymphoma grade or transformation in cytologic material. We counted transformed lymphocytes in fine-needle aspiration (FNA) biopsy specimens to determine whether the percentage of these cells in the smear could predict the histologic grade, the biologic behavior, or both. The percentage of transformed lymphocytes out of total lymphoid cells was determined on Papanicolaou-stained smears. Afterward, a cytodiagnosis was based on clinical information available at the time of the FNA, cytomorphologic data, and flow cytometry data. Results were correlated with results of examination of the surgical biopsy specimen, clinical behavior of the lymphoma, or both. The percentage of transformed lymphocytes was 10% or less in all low-grade or indolent lymphomas. Aspirates with transformed lymphocyte counts of 20% or greater were aggressive lymphomas. We also report our experience in the diagnosis of non-Hodgkin's lymphoma by FNA using cytomorphologic examination and immunophenotyping by flow cytometry at a cancer referral hospital. This is a preliminary study, and larger series may help establish the ranges of transformed lymphocyte counts that correlate with the lymphoma subtype.

Nipple aspirate fluid: a promising non-invasive method to identify cellular markers of breast cancer risk

To evaluate the feasibility of nipple aspiration and to identify intermediate markers of breast cancer risk, nipple aspirate fluid (NAF) was collected from 177 subjects using a modified breast pump. The first 33 subjects demonstrated that we could obtain NAF quickly, reliably and repeatedly. Specimens from the remaining 144 subjects were collected to evaluate promising cellular biomarkers. NAF was obtained in 167 out of 177 (94%) subjects overall and in 99% of the 144 most recent subjects. Sufficient NAF was obtained to evaluate cytology in 160 out of 167 (96%) cases and specimens were sufficiently cellular to analyse DNA markers in 53% of cases. Among the last 144 subjects, menopausal status did not influence the ability to obtain NAF. NAF cytology correlated with increased breast cancer risk (P = 0.002). Using computerized image analysis of NAF epithelial cells, DNA index (P = 0.0002), percentage of cells in G2M (P = 0.05) and percentage of cells with hypertetraploidy (P = 0.002) increased as cytology became more abnormal. Our data indicate that NAF can be obtained in essentially all eligible subjects; that breast epithelial cells are evaluable in > 95% of NAF samples for cytology and in over half of NAF samples for DNA index (ploidy) and cell cycle analysis; and that abnormal NAF cytology correlates with increased breast cancer risk. This suggests that biomarkers identified in nipple aspirate fluid may prove useful either as an adjunct to currently accepted breast cancer screening methods, or to evaluate response to a chemopreventive agent.

Primary combined malignant melanoma and ductal carcinoma of the breast. A report of two cases

BACKGROUND

Tumors consisting of a combination of malignant melanoma and carcinoma are very rare. The authors report two such cases occurring as primary breast tumors.

METHODS

The breast tumors were analyzed by histologic, immunohistochemical, and ultrastructural techniques.

RESULTS

Histologically, the tumors were composed of a closely related admixture of ductal adenocarcinoma and malignant melanoma with abundant melanin pigment. Ductal carcinoma in situ was identified in both cases, confirming their origin in the breast. In both tumors, double-labeling immunohistochemistry showed that the epithelial component was immunoreactive for cytokeratin, the melanoma component was immunoreactive for HMB45, and both components were immunoreactive for S-100 protein. Immunostains for estrogen and progesterone receptors were negative in both tumors. Electron microscopy demonstrated glandular lumens and junctional complexes in the epithelial component and melanosomes and premelanosomes in the melanoma component. In one of the cases, rare tumor cells contained both premelanosomes and desmosomes.

CONCLUSIONS

Combined malignant melanoma and carcinoma is a rare tumor. Only a handful of cases have been reported. The authors report two such cases occurring as primary tumors of the breast. The histology of the tumors revealed a closely related admixture of pigmented malignant melanoma and ductal carcinoma. Double-labeling immunohistochemistry showed that cytokeratin and HMB45 were expressed in the tumors, but not within the same cells. The authors propose describing this type of lesion as a single tumor of breast origin with bidirectional differentiation.

Choroidal melanoma in an African-American albino

PURPOSE

To report the rare occurrence of choroidal melanoma in an African-American albino.

METHODS

A 68-year-old African-American man with oculocutaneous albinism developed an amelanotic choroidal mass in his left eye. A transvitreal fine-needle aspiration biopsy was performed to confirm the diagnosis, and the patient was treated with iodine 125 plaque radiotherapy.

RESULTS

The cytology of the needle biopsy showed spindle cells with nuclear atypia and prominent nucleoli. The cells showed positive immunoreactivity for HMB-45, supporting the diagnosis of choroidal melanoma.

CONCLUSION

To our knowledge, this is the first reported case of a choroidal melanoma occurring in an African-American albino.

Prostate-specific antigen levels in nipple aspirate fluid correlate with breast cancer risk

Despite the fact that breast cancer is the most common non-cutaneous cancer and a leading cause of cancer deaths in women, accepted markers of breast cancer risk miss up to 40% of these tumors. Moreover, screening methods involving the analysis of tissue or cells are limited by the need for a surgical biopsy. Nipple aspiration is a quick, efficient, noninvasive method to obtain breast epithelial cells, the cells at risk for transformation to carcinoma. Prostate-specific antigen (PSA), a protein thought to be specific to the prostate but recently found in a subset of breast tumors, has been correlated with improved survival. The purpose of this study was to measure PSA in a group of women with increasing breast cancer risk (no risk or family history of breast cancer, precancerous mastopathy, and invasive cancer) and determine if PSA correlates with risk. Nipple aspirate fluid was obtained from the intact breast and from surgical specimens using a modified breast pump. PSA was then measured in the fluid using a highly sensitive and specific immunofluorometric procedure. PSA was found at levels ranging from 0-13,423 ng/g of total protein, and there was a significant relationship between PSA level and breast cancer risk (P = 0.001). That is, all women with no risk factors and 90% of those with a family history had high PSA levels, whereas 68% of subjects with precancerous mastopathy or invasive cancer had low PSA levels. PSA was higher in premenopausal subjects (P = 0.002). After adjusting for the effect of menopausal status, there remained a significant association between PSA and breast cancer risk. These findings suggest that PSA in nipple aspirate fluid may be a useful marker of breast cancer risk.

Recurrent systemic B cell lymphoma of the iris

Images

Atypical retinal astrocytic hamartoma diagnosed by fine-needle biopsy

BACKGROUND

Retinal astrocytic hamartoma and retinoblastoma may be very similar clinically, and their differentiation in atypical cases can be difficult, even with the use of ancillary methods such as fluorescein angiography, ultrasonography, and computed tomography. To the authors knowledge, fine-needle aspiration biopsy has not been used to diagnose astrocytic hamartoma in such cases.

PATIENTS AND METHODS

A 7-week-old boy had a minimally calcified retinal mass in the macular area of the left eye associated with an extensive secondary retinal detachment. The differential diagnosis included retinal astrocytic hamartoma and retinoblastoma. A transvitreal fine-needle aspiration biopsy was performed.

RESULTS

The cytology of the needle biopsy showed benign spindle and stellate cells, which were compatible with glial cells. The lesion had immunoreactivity for glial fibrillary acidic protein, further supporting the diagnosis of astrocytic tumor.

CONCLUSION

Fine-needle aspiration biopsy is diagnostically useful in unusual cases where the differential diagnosis between retinoblastoma and astrocytic hamartoma is difficult.

Cytologic diagnosis of upper urinary tract neoplasms by ureteroscopic sampling

During a three-year period, 160 cytologic specimens from the upper urinary tract (UUT) were collected from 62 patients. The specimens were obtained during ureteroscopy using various sampling techniques, including washing, brushing, aspiration and minute biopsies. The patients ranged from 17 to 84 years of age and consisted of 32 men and 30 women. For each patient one diagnosis that indicated the highest degree of abnormality was selected. These consisted of 23 "malignant," 9 "suspicious for malignant," 19 "atypical," 8 "negative for malignancy" and 3 "unsatisfactory" diagnoses. Of 30 patients with a malignant or suspicious diagnosis for whom adequate clinical and follow-up information was available, 18 had histologic confirmation of malignancy, and the other 12 had clinical and endoscopic evidence of neoplasms. Of 15 patients with an atypical diagnosis and adequate follow-up, 2 proved to have low grade transitional cell carcinoma, 1 had a fibroepithelial polyp, and 12 had clinical, endoscopic and follow-up evidence of nonneoplastic conditions. None of the 11 cases with negative or unsatisfactory diagnoses was found to have a malignant neoplasm. Because of the difficulty in obtaining adequate biopsies from UUT lesions, cytologic examination is the most practical method of diagnosis. This study indicated that highly accurate results are achieved, with close correlation between endoscopic and cytologic findings.

Utility of polyclonal and monoclonal antibodies against carcinoembryonic antigen in hepatic fine-needle aspirates

To assess the usefulness of polyclonal and monoclonal antibodies against carcinoembryonic antigen (CEA) in the differential diagnosis of hepatocellular carcinoma (HCC) vs. metastatic adenocarcinoma (MA), we studied 25 cases of fine-needle aspirates (FNA) of hepatic lesions. The material consisted of 9 primary HCCs, 8 MAs, and 8 benign hepatic aspirates. For immunostaining, the avidin-biotin complex technique was performed on paraffin sections of cell blocks, using a standardized automatic immunostainer. Specific bile canalicular immunostaining with polyclonal CEA (pCEA) antibody was present in five of eight (5/8) benign hepatic aspirates and eight of nine (8/9) HCCs. Diffuse cytoplasmic immunostaining with pCEA antibody was present in four of eight (4/8) MAs. None of the aspirates showed any positive immunostaining with monoclonal CEA (mCEA) antibody. We conclude that: (1) pCEA antibody is useful in the evaluation of hepatic FNAs. Diffuse cytoplasmic staining is seen in MAs, whereas canalicular immunostaining pattern is an indication of benign or malignant hepatocytes. (2) Paraffin-embedded cell blocks made from hepatic aspirate material are suitable for immunostaining with polyclonal CEA antibody. (3) mCEA antibody has no value in the diagnosis of HCC.

Interobserver variability of cervical smears with squamous-cell abnormalities: a Philadelphia study

The reproducibility of reporting squamous lesions by the Bethesda System (TBS) was evaluated by distributing 20 slides to be classified among 5 panelists considered experts in the field of cytopathology. Four cases were chosen for their classic morphology and the remainder were foreseen to produce possible discrepancies within one diagnostic category. For 7/20 (35%) cases there was unanimous agreement. Participants disagreed within one category of magnitude for seven (35%) cases. In six (30%) cases there was a range of more than one category disagreement. However, additional written comments modifying TBS diagnoses often diminished the clinical significance of these discrepancies. We conclude that despite the important role of TBS in standardization of Pap smear reports, a great degree of subjectivity exists in classifying squamous abnormalities without "classic" morphology. The lack of reproducibility should be taken into account in cytology proficiency testing.

Ureteroscopic biopsy in the upper urinary tract

OBJECTIVES

To determine the optimal instruments and techniques for biopsy of upper urinary tract lesions through the small working channel in flexible and small semirigid ureteroscopes.

METHODS

Urinary tract filling defects and other lesions were accessed with rigid or flexible ureteroscopy and biopsies were done using one or more devices: a 3 F cup biopsy forceps, 2.5 F and 3 F baskets, 2.5 F and 3 F graspers, 3 F snare, brush, and aspiration catheters. All samples, including the cup forceps samples, were sent for cytopathologic study, with those containing grossly visible tissue particles processed as a cell block. Only those specimens reported definitely positive or negative were considered diagnostic, whereas the others were grouped as nondefinitive. Not all sampling techniques could be used in every patient because of the size of the lesion and the technical limitations, including bleeding and instrument position during biopsy.

RESULTS

There were 55 procedures in 43 patients. The indications included hematuria, filling defect, abnormal cytology, and periodic surveillance. A basket was used in 22 procedures and gave unequivocal results in 15. The other samples were equivocal, nondiagnostic, or unsuitable. The biopsy forceps provided a definitive result in 16 of 21 samples and the grasper was definitive in 5 of 6 samples. We could not obtain a suitable specimen using a snare in 2 cases and the brush gave a definitive result in only 5 of 11 cases. Samples of aspirate and washings were definitive in less than 50% of instances but detected some tumors for which other techniques were equivocal.

CONCLUSIONS

For the best results, the largest biopsy specimen possible should be obtained. Aspiration or wash alone is often not diagnostic but can give a diagnosis in some patients. Tissue sampling devices, such as the forceps and basket, have an advantage in obtaining a larger sample. Cytopathologic techniques are particularly useful for handling and interpreting the small specimens obtained with ureteroscopic biopsy techniques.

Fine-needle aspiration biopsy of suspected intraocular tumors. The 1992 Urwick Lecture

BACKGROUND

Fine-needle aspiration biopsy recently has been used as a diagnostic modality for selected intraocular tumors and simulating conditions. However, the value of fine-needle aspiration biopsy for intraocular tumors previously has not been clarified.

METHODS

Transocular fine-needle aspiration biopsy was performed on selected patients who had intraocular lesions that were suspected clinically to be neoplasms but in which there was diagnostic uncertainty based on noninvasive clinical evaluation. These cases were analyzed to determine accuracy, complications, and limitations of the technique.

RESULTS

Of 6500 patients referred to the Oncology Service for evaluation of possible intraocular tumor, transocular fine-needle aspiration biopsy was used clinically in 159 cases (2.4%). It proved to be a reliable diagnostic method for intraocular malignancies such as uveal melanoma, uveal metastasis, retinoblastoma, lymphoma, and leukemia. In the 140 cases (88%) in which adequate cytologic material was obtained, the sensitivity rate was 100% and the specificity rate was 98%. In 19 cases where the cytologic material was too scant to render a diagnosis, the sensitivity rate was 84% and the specificity rate was 98%. The problem of insufficient material for cytologic diagnosis has been greatly minimized with the recent use of a 22-gauge needle. The main complication was localized intraocular hemorrhage. Retinal detachment and tumor recurrence have not been observed.

CONCLUSIONS

Transocular fine-needle aspiration biopsy is a safe and reliable diagnostic method for suspected intraocular tumors and inflammatory conditions in which noninvasive diagnostic modalities have failed to establish the diagnosis and in which cytologic verification of the diagnosis is necessary to institute appropriate treatment. Although the authors have had few complications with fine-needle aspiration biopsy, the technique should be reserved for selected cases where the diagnosis has not been established by less-invasive diagnostic measures.

Flow cytometric DNA analysis of interleukin-2 responsive renal cell carcinoma

Adoptive immunotherapy using interleukin-2 (IL-2) based therapy can result in marked tumor regression in some patients with metastatic renal cell carcinoma. DNA flow cytometry has not been previously studied as a predictor of outcome of this therapy. Archival paraffin embedded tumors were studied in 23 IL-2 treated patients with metastatic renal cell carcinoma. Eleven patients were complete responders (CR) and 12 were nonresponders (NR). In the CR group, 4/11 (40%) were diploid and 7/11 (60%) were aneuploid. In the NR group, 9/12 (75%) were diploid and 3/12 (25%) were aneuploid. Although there was a trend that patients with an aneuploid DNA pattern were more likely to undergo a complete response, ploidy pattern alone was not significantly predictive of response (p2 = 0.10, Fischer's exact test). When combining ploidy pattern with other variables that were predictive for complete response, such as good performance status and a higher pretreatment weight, prediction of complete response was not improved by including ploidy. This preliminary report suggests that DNA ploidy does not appear to provide any additional information concerning responsiveness to IL-2 based immunotherapy beyond that obtained by performance status and pretreatment weight in this patient population.

Fine needle aspiration biopsy in pediatric ophthalmic tumors and pseudotumors

In an eight-year period (1983-1990) approximately 500 fine needle aspiration biopsies (FNABs) of eye lesions were processed in our laboratory. Eighty-one of the cases, obtained from 77 pediatric patients (ranging from 4 weeks to 16 years of age), were the subject of this study. The specimens included 73 intraocular and 8 orbital aspirates. Forty-four of the specimens were from diagnostic procedures, whereas 37 were obtained from surgical specimens immediately after enucleation. Eight FNABs (four diagnostic and four postenucleation) were deemed inadequate for cytologic diagnosis. Of the remaining 73 cases, 38 were diagnosed as malignant (34 retinoblastomas, 3 medulloepitheliomas, 1 rhabdomyosarcoma), and all were confirmed upon subsequent histologic examination. Four cases were diagnosed as suspicious for malignancy; all of them proved to be malignant (two retinoblastomas, two rhabdomyosarcomas). One orbital aspirate contained cells suggestive of a glial origin and was confirmed histologically as pilocytic astrocytoma. Ten cases were reported as compatible with Coats' disease; all were confirmed to be benign by histologic examination (three cases) or clinical follow-up (seven cases). The remaining 20 benign aspirates (13 with inflammatory cells, 6 with macrophages and 1 with blood) proved to be from benign conditions by histologic examination (4 cases) or clinical follow-up (16 cases). There were no false-positive diagnoses. The overall accuracy of FNAB was 95%, and the accuracy of cytologic interpretation was 100%. We conclude that FNAB is a reliable and accurate diagnostic modality in the assessment of selected pediatric ophthalmic diseases.

Detection of growth fraction in tumors by Ki67 monoclonal antibody in cytologic smears: a prospective study of 40 cases

The monoclonal antibody (MAb) Ki67 detects a nuclear antigen in cycling tumor cells. Quantitation of proliferating cells is helpful in predicting the recurrence and metastatic potential of tumors as previously reported. We conducted a prospective study on 40 benign and malignant tumors by performing Ki67 immunocytochemical stains on cytologic smears and their corresponding frozen tissues. Quantitation of Ki67 positive cells was done by counting 300 cells in 5-7 high-power fields in cytologic smears and tissues. Only nuclear or nucleolar immunostaining was considered positive for MAb Ki67. The number of Ki67 positive tumor cells in cytologic smears correlated well with Ki67 positive cells from corresponding tissues. On the average, cytologic smears showed 1.9% higher Ki67 positivity in malignant tumors as compared to their corresponding frozen tissues (P < 0.001). The Ki67 positivity in malignant tumors was found to be significantly higher when compared with benign tumors (P < 0.001). We conclude that cytologic smears can be used for the determination of growth potential in tumors by MAb Ki67. Additionally, cytologic preparations can be used during intraoperative consultations when adequate tissue is not available for the above mentioned study.

Needle aspiration cytology of the irradiated breast

During a 3-year period (1987-1989), 60 fine-needle aspiration biopsies (FNAs) were obtained from new breast lesions in patients previously treated by radiation and surgery for breast carcinoma. The lesions occurred at or near the site of previous excision, 3-117 months after initiation of radiotherapy. FNAs were classified as follows: acellular (11); negative (29); atypical (13); suspicious (4); and positive (3). For statistical analysis, acellular, negative, and atypical diagnoses were considered negative findings, and suspicious and positive diagnoses were considered positive findings. On the basis of subsequent biopsy and/or patient follow-up, FNA yielded a sensitivity of 86%, a specificity of 98%, a positive predictive value of 86%, a negative predictive value of 98%, and an efficiency of 97%. Excluding cystic lesions, the most reliable criterion for distinguishing malignant from benign lesions was the abundance of epithelial cells, both singly and in large clusters. Cellular characteristics were less helpful, since nuclear atypia was seen in both benign and malignant lesions. It is concluded that (1) FNA is a reliable technique in the evaluation of the irradiated breast; (2) when performed by an experienced operator, an acellular aspirate may be interpreted as evidence against recurrent carcinoma; and (3) epithelial atypia must be interpreted with caution to avoid a false-positive diagnosis.

Significance of pericellular lacunae in cell blocks of effusions

A retrospective study was conducted to assess the usefulness of pericellular lacunae in cell block sections of serous effusions in diagnosis. From January to December 1988, 286 cell blocks were prepared in our laboratory from pleural, pericardial and peritoneal fluids; 62 of them were excluded from this study because of inadequate cellularity, diagnostic uncertainty or lack of a proteinaceous background. The remaining consisted of 148 benign effusions from 128 patients and 76 malignant effusions from 56 patients. A single specimen from each patient was selected and reviewed to assess the presence and number of pericellular lacunae and to determine the relationship of this feature to cell arrangement (single cells versus cell clusters). Pericellular lacunae were found in 42 (75%) of the malignant effusions as compared to 41 (32%) of benign specimens. In the majority of malignant cases with lacunae, this feature was associated with greater than two-thirds of the cells, whereas in benign cases, when present, it was seen in less than one-third of the cells. Neoplasms characterized by large cell clusters more frequently had lacunae than did those with small groups or single cells. Lacunae were not evident in cases of malignant melanoma and lymphoma. We conclude that although pericellular lacunae are more often associated with malignant cells, their presence in itself cannot be used as a reliable indicator of malignancy in body cavity fluids.

Effusion cytology

Cytologic evaluation is the best way to detect the presence of malignancy in body cavity fluids. Although a positive diagnosis is highly reliable, a negative result does not rule out a malignant cause. Adenocarcinomas, well-differentiated squamous carcinomas, small-cell carcinomas, malignant melanomas, large-cell lymphomas, and acute leukemias are accurately classified when present in effusions. The definitive diagnosis of malignant mesothelioma, small-cell lymphomas, and chronic leukemias, and subclassification of sarcomas and poorly differentiated neoplasms are difficult and may require additional diagnostic techniques. With a few exceptions, the exact causes of benign effusions cannot be determined by cytologic methods.

Brush cytology in the diagnosis of colonic neoplasms

During a three-year period (1986-1988), 234 colonic brush specimens were received in the authors' laboratory. Nine samples (4%) were deemed unsatisfactory for evaluation because of inadequate cellularity and/or poor fixation. In 11 cases concomitant or follow-up histologic specimens were not available. The remaining 214 specimens included 82 malignant neoplasms, 88 neoplastic polyps (adenomas), and 44 nonneoplastic lesions. Sixty-seven (82%) of malignant neoplasms were correctly diagnosed by brush cytology. Three cases of adenoma with severe dysplasia or in situ carcinoma were diagnosed as adenocarcinoma by cytology. No false-positive diagnoses were made of nonneoplastic lesions. Brush cytology was found to be a more sensitive technique in the diagnosis of colon cancer than endoscopic biopsy (82% and 74% sensitivity, respectively). The combination of the two techniques increased the sensitivity to 90% and improved the overall accuracy of the test. Seventy-one (82%) of the colonic adenomas were correctly diagnosed by cytology. Brush cytology is a convenient, safe, and accurate technique which should be used concurrently with endoscopic biopsy or polypectomy.

Aspiration cytology of papillary cystic neoplasm of the pancreas

The authors present a case of papillary and cystic neoplasm of the pancreas (PCN) in which fine-needle aspiration was performed intraoperatively. Only a few reports of fine-needle aspiration of this rare tumor have been published. The features most helpful in reaching a diagnosis of PCN were a monotonous population of tumor cells, round to oval bland-appearing nuclei, scanty to moderate ill-defined cytoplasm, and the presence of numerous capillaries. Despite the lack of branching papillary clusters described in previous reports, it was possible to suggest the correct diagnosis by identifying these other characteristic features. In addition, estrogen and progesterone receptor levels were measured and found to be negligible. A review of the literature with emphasis on cytologic features also is presented.

Liesegang rings in renal cyst fluid

Peculiar ring-like structures identified as Liesegang rings (LRs) were found in renal cyst fluid from three patients with benign renal cysts. They ranged in size from 5 to 820 mu. Most had a double-layer outer wall with equally spaced radial cross-striations and an amorphous central nidus. Special stains were performed in one case, and the results are discussed. Reports of LRs in cystic or inflamed tissues have recently appeared in the literature. Some LRs have been mistaken for eggs or mature components of the giant kidney worm, Dioctophyma renale. We propose that cytologic assessment of renal cyst fluid in conjunction with histologic examination decreases the likelihood of misdiagnosis of LRs.

Brushing cytology in biliary tract obstruction

During a period of eight years (1980 to 1987), cytologic samples were obtained by brushing and reverse screw devices from 54 patients undergoing transhepatic cholangiography for evaluation of obstructive jaundice. Eight patients were excluded from this study, seven for inadequate follow-up and one because of unsatisfactory cytologic material. Of the remaining cases, 32 were cytologically diagnosed as adenocarcinomas; all but one patient proved to have malignant disease by histologic examination and/or through clinical follow-up. These included 21 pancreatic carcinomas, 6 bile duct carcinomas, 1 ampullary carcinoma, 1 gallbladder carcinoma and 2 metastatic carcinomas. In one case, the diagnosis of malignancy was found to be in error upon review of the cytologic smears. Of 14 patients with negative cytologic diagnoses, 7 were found to have malignant neoplasms and 7 had benign diseases. These findings indicate that, while a positive cytologic diagnosis is a reliable indicator of a malignant biliary obstruction, a negative result does not exclude malignancy.

Detection of Chlamydia trachomatis in cervical smears from pregnant population

Specimens were obtained for chlamydial cultures and for routine cytologic studies from 281 consecutive pregnant women who presented for their first prenatal visit. Forty patients (14%) had positive cultures for Chlamydia trachomatis. The cervical smears from all patients with positive cultures and from an equal number of age-matched patients with negative cultures were screened for cytologic features reported to be associated with Chlamydia infection. The following features were noted to be more common in the patients with positive cultures: squamous metaplasia, cytoplasmic vacuolation, nuclear abnormalities, human papillomavirus-associated changes, and a greater degree of inflammation. Cytoplasmic inclusions were present in only a single cell in each of 4 (10%) of the patients with positive cultures. None of the cytologic findings was considered to be specific enough to allow a diagnosis of Chlamydia infection. In our experience, the evaluation of cervical smears is of limited value in the detection of Chlamydia infection in pregnant women.

Fine needle aspiration cytology of retroperitoneal paraganglioma with lipofuscin pigmentation

The cytologic features observed in fine needle aspiration smears and cell blocks from a retroperitoneal paraganglioma are described. The aspirate contained clusters of uniform cells of medium size, with ill-defined borders, round nuclei and evenly dispersed chromatin. An unusual feature was the presence of cytoplasmic pigment, which proved to be lipofuscin by histochemical staining and electron microscopy. The histologic and ultrastructural findings, as well as the results of histochemical and immunodiagnostic staining, are also presented.

Nuclear grooves in the aspiration cytology of papillary carcinoma of the thyroid

Nuclear grooving has recently been shown to be a useful morphologic feature in the diagnosis of papillary carcinoma of the thyroid in tissue sections and imprint smears. In order to assess the diagnostic value of nuclear grooving in cytologic specimens, the presence of this feature was evaluated in fine needle aspirates from 20 papillary carcinomas of the thyroid, 10 follicular adenomas, 3 follicular carcinomas, 1 medullary carcinoma, 10 nodular goiters and 4 cases of Hashimoto's thyroiditis. In each case, 30 random high-power fields (HPFs), or all fields in less cellular smears, were examined, and the percentage of the fields in which nuclear grooving could be seen was recorded. Seventeen of 20 papillary carcinomas (85%) showed nuclear grooves in more than 25% of the HPFs examined; in the remaining three cases, grooves were observed in less than 25% of the HPFs. In control cases (all other thyroid lesions), nuclear grooves either were absent or were present in less than 25% of the HPFs examined. These findings suggest that nuclear grooving, when seen in abundance, can be considered a reliable criterion for the diagnosis of papillary carcinoma in fine needle aspiration cytology of the thyroid. The presence of occasional grooves, however, should be regarded as a nonspecific finding.

Multiple myeloma involving the iris

Intraocular invasion by neoplastic plasma cells is a rare ophthalmic manifestation of plasma cell dyscrasias. A 67-year-old man who had documented multiple myeloma presented with an infiltration of the iris that simulated a nongranulomatous uveitis. Cytologic examination of the aspirate obtained by anterior chamber paracentesis demonstrated that the infiltrate was composed of neoplastic plasma cells.

Positive effusion cytology as the initial presentation of malignancy

During a period of four years (1981 to 1984), 641 ascitic, 860 pleural and 47 pericardial fluid specimens were examined cytologically. Of these, 154 ascitic samples, 174 pleural specimens and 10 pericardial effusions, obtained, respectively, from 108, 133 and 7 patients, were found to contain malignant cells. In 7 patients, ascites, and in 18 cases, pleural effusions were the first indication of cancer. None of the positive pericardial fluids was the initial presentation of malignancy. The cytologic findings and follow-up data on these 25 patients are the subject of this study. The most common type of neoplasm in these effusions was adenocarcinoma (86% of the ascitic and 78% of the pleural fluids). Most of the malignant neoplasms in ascitic fluids were derived from ovarian tumors (5 of 7) while those in pleural effusions came mainly from lung tumors (12 of 18). Mammary carcinoma, which was the most common malignant tumor found in cases of pleural effusions, did not present initially with an effusion in any of our cases. The cytologic diagnosis was confirmed in all cases by either biopsy or strong clinical evidence. The prognosis in patients who initially presented with an effusion was poor. All of the patients with an adequate follow-up died within 29 months in cases of ascites and within 19 months in cases of pleural effusions.

The cytologic diagnosis of mesothelioma

The cytologic features of malignant mesothelioma cells in serous effusions are presented. Carcinomatous mesotheliomas are characterized by abundant neoplastic cells occurring singly and in clusters. The optically dense cytoplasm with lacy peripheral vacuoles, scalloped borders of cell clusters, intercellular spaces, "cell-in-cell" arrangement, and frequent multinucleation of cells are features of malignant mesothelioma, but none is pathognomonic of this tumor. A positive cytoplasmic staining of tumor cells with periodic acid-Schiff (PAS) after diastase digestion, and with mucicarmine stain after hyaluronidase treatment are against the diagnosis of mesothelioma, while positive staining with alcian blue, which becomes negative after the treatment with hyaluronidase is strongly suggestive of mesothelioma. The tumor cells react with antibodies to cytokeratin and vimentin, and do not react with carcinoembryonic antigen. Ultrastructurally, mesothelioma cells are characterized by long slender branching microvilli and numerous pinocytotic vesicles. They lack mucin vacuoles and intracellular lumens. An accurate diagnosis of mesothelioma depends on a full knowledge of the clinical history and radiologic findings, and proper application of histochemical, immunodiagnostic, and electron microscopic techniques.

Detached ciliary tufts in pouch of Douglas fluid

Detached ciliary tufts were observed in fluid obtained during laparoscopy from the pouch of Douglas of a young woman with secondary infertility. Previous reports of this finding are reviewed, and various etiologic factors in the production of these structures are discussed. This phenomenon appears to be a normal physiologic condition that results from exfoliation of the distal portion of the fallopian tube epithelial cells, possibly under the influence of progesterone in the luteal phase of the menstrual cycle.