Faculty Bibliography

Introduction: Metastatic neoplasms (MN) are rare in the pancreas. An accurate diagnosis is challenging because MNs mimic primary pancreatic neoplasms, both clinically and on cytology. However, the distinction is critical for patient management. In this study, we reviewed our experience in diagnosing MNs by EUS-FNA of the pancreas. Material and Methods: We searched our database for pancreatic EUS-FNA specimens with a diagnosis of MN from 1994 to 2014. The clinical history, radiologic findings and follow-up of these cases, if available, were reviewed. Results: There were 17 cases of MNs to the pancreas in 7 males and 10 females, ranging in age from 37 to 85 years (mean = 62). The primary malignancies included carcinomas of the lung (4), colon (3), breast (2), ovary (1), kidney (1), liver (1), melanoma (3) and sarcoma (2). The pancreatic head and neck were the most common locations (73%).16 cases (94%) had a known prior history of malignancy; the clinical history was not provided in one case. All cases presented as a single mass in the pancreas. The average tumor size was 1.9 cm (range: 0.5 - 4 cm). 12 cases (71%) were poorly-differentiated carcinomas, indistinguishable from a pancreatic adenocarcinoma without immunohistochemical (IHC) studies and/or clinical history. 12 (71%) cases were correctly diagnosed as MN, 3 (18%) cases had indeterminate tumor origin, and 2 (12%) were misdiagnosed as primary pancreatic adenocarcinoma. A correct diagnosis was reached by cytomorphology alone in 3 cases (18%); morphology and immunohistochemical stains in 7 cases (41%); and morphologic comparison to the prior tumors in 2 cases (12%). Conclusions: EUS-FNA is an effective approach to diagnose pancreatic tumors. MNs can be difficult to differentiate from primary pancreatic carcinomas based on cytology alone. Clinical history and adequate cell block for IHC studies are essential to reach an accurate diagnosis

Background Tracheobronchopathia osteochondroplastica is a rare benign and often indolent disease. We report the first case of tracheobronchopathia osteochondroplastica (TBO) presenting as acute hypercarbic respiratory failure due to superimposed subglottic submucosal abscess. Case Report A 27-year-old man presented to the emergency department in respiratory distress that required mechanical ventilation for acute hypercarbic respiratory failure. Upon extubation the next day, stridor was elicited with ambulation. Spirometry revealed fixed upper airway obstruction. Neck imaging showed a 2.8x2.0x4.0 cm partially calcified subglottic mass with cystic and solid component obstructing 75% of the airway. Surgical exploration revealed purulent drainage upon elevation of the thyroid isthmus and an anterolateral cricoid wall defect in communication with a subglottic submucosal cavity. Microbiology was negative for bacteria or fungi. Pathology showed chondro-osseous metaplasia compatible with tracheobronchopathia osteochondroplastica (TBO). The patient received a course of antibiotics and prophylactic tracheostomy. Since tracheostomy removal 3 days later, the patient remains asymptomatic. Conclusions Tracheobronchopathia osteochondroplastica is a rare disease with usually benign clinical course and incidental diagnosis. It may present as acute hypercarbic respiratory failure when subglottic infection is superimposed.

Myelolipomas are benign tumors, histologically consisting of an admixture of mature adipose tissue and normal hematopoietic elements. It is most commonly found in the adrenal glands. Extra-adrenal myelolipomas are rare. Due to the rarity of this entity, exposure to and awareness of the cytological characteristics are limited. We report a case of intra-abdominal extra-adrenal myelolipoma diagnosed by fine needle aspiration (FNA) in a 67-year-old female, and review of relevant English literature. Knowledge of the cytological features of myelolipoma will avoid mistaking this benign tumor as malignant.

Pneumocystis pneumonia is a common component of the acquired immunodeficiency syndrome (AIDS) in the United States. Extrapulmonary pneumocystosis, however, is much less common. Rare cases have been reported in lymph nodes, bone marrow, spleen, pleura, gastrointestinal tract, liver, common bile duct, pancreas, skin, thyroid, and eye. A 39-yr-old man with history of chest wall injuries from gunshot and stabbing presented with multiple pleural masses clinically suspicious of metastatic deposits from an unknown primary. Fine-needle aspiration biopsy of the largest pleural mass revealed extrapulmonary pneumocystis, which led to the diagnosis of AIDS. Similar to the previous reports of pneumocystis mass lesions in extrapulmonary sites, the current case is associated with exuberant vascular proliferation and Langhans' giant cell reaction. Neovascularization and histiocytic influx from the newly formed blood vessels and Langhans' giant cell reaction seem to be a common tissue reaction to the massive deposition of pneumocystis organisms in extrapulmonary sites in patients with AIDS. Diagn. Cytopathol. 2005;33:97-99. (c) 2005 Wiley-Liss, Inc

Lymphomas of the breast are rare and may mimic carcinoma clinically. We investigated the ability of fine-needle aspiration (FNA) biopsy combined with adjunctive flow cytometry (FC), immunofluorescence microscopy (IFM), and immunocytochemistry (ICH) to diagnose and eventually subclassify lymphomas of the breast according to the Revised European American Lymphoma/World Health Organization classification. We retrieved 21 breast aspirates from 19 patients with a cytologic diagnosis of lymphoma or plasmacytoma over a 10-year period (1992-2002), excluding 98 benign intramammary lymph nodes and 1 atypical lymphohistiocytic proliferation (Rosai Dorfman disease). FC was performed in 15/21 aspirates, IFM in 1/21, ICH in 3/21. Histologic follow-up (HF) was obtained for 10 patients, most of them with primary lymphoma. For the remaining nine patients without HF, flow cytometric analysis, comparative morphology, or remission after chemotherapy regimens supported the cytologic diagnosis. Of 19 patients, 11 patients had a secondary lymphoma (SL) and 8 patients had a primary lymphoma (PL). FNA and FC/IFM/ICH classified 7/8 PLs as B-cell lymphomas and 1/8 PLs as plasmacytoma. However, FNA could only subclassify 3 of 8 PLs. FNA and/or FC subclassified accurately 10/11 SLs. All cases were accurately immunophenotyped as B-, T-cell non-Hodgkin's lymphomas or plasmacytoma. World Health Organization classification was achieved in 3/8 PLs (42%) and 10/11 SLs (91%; P = 0.04). Subclassification (which has an impact on long-term management and prognosis) was significantly better in SL, when a previous histologic diagnosis had already been made, when compared to PL, of which 5/8 cases (62.5%) could not be accurately classified. Diagn. Cytopathol. 2004;30:332-340