Faculty Bibliography

Synopsis We report the utility of office-based, nonimaged guided fine needle aspiration of palpable axillary lymph nodes in breast cancer patients. We examine the sensitivity and specificity of this procedure, and examine factors associated with a positive fine needle aspiration biopsy result. Abstract: Although the utility of ultrasound-guided fine needle aspiration biopsy (FNA) of axillary lymph nodes is well established, there is little data on nonimage guided office-based FNA of palpable axillary lymphadenopathy. We investigated the sensitivity and specificity of nonimage-guided FNA of axillary lymphadenopathy in patients presenting with breast cancer, and report factors associated with a positive FNA result. Retrospective study of 94 patients who underwent office-based FNA of palpable axillary lymph nodes between 2004 and 2008 was conducted. Cytology results were compared with pathology after axillary sentinel node or lymph node dissection. Nonimage-guided axillary FNA was 86% sensitive and 100% specific. On univariate analysis, patients with positive FNA cytology had larger breast tumors (p = 0.007), more pathologic positive lymph nodes (p < 0.0001), and were more likely to present with a palpable breast mass (p = 0.006) or with radiographic lymphadenopathy (p = 0.002). FNA-positive patients had an increased presence of lymphovascular invasion (p = 0.001), higher stage of disease (p < 0.001), higher N stage (p < 0.0001), and higher rate of HER2/neu expression (p = 0.008). On multivariate analysis, radiographic lymphadenopathy (p = 0.03) and number of positive lymph nodes (p = 0.04) were associated with a positive FNA result. Nonimage-guided FNA of palpable axillary lymphadenopathy in breast cancer patients is an inexpensive, sensitive, and specific test. Prompt determination of lymph node positivity benefits select patients, permitting avoidance of axillary ultrasound, sentinel lymph node biopsy, or delay in receiving neoadjuvant therapy. This results in time and cost savings for the health care system, and expedites definitive management

Plasmablastic lymphoma (PBL) is a rare lymphoma originating from B-cells with terminal differentiation. Most common anatomic site involved by PBL is the oral cavity. Involvement of other body sites has only rarely been reported. Herein, we report a rare case of EBV-negative PBL involving the breast of an HIV positive 47-year-old woman. The patient presented with decreased vision and photophobia. During physical examination, she was found to have bilateral breast masses and multiple lymphadenopathy. Fine-needle aspiration of one of the breast masses showed large malignant cells with plasmacytoid features. Immunohistochemical studies performed on the core biopsy showed that the tumor cells were positive for common leukocyte antigen CD45 and plasma cell marker CD138, but negative for the pan-B cell markers CD20 and CD79a. Molecular genetic studies showed clonal rearrangement of the immunoglobulin kappa light chain gene. This is the first case of PBL involving the breast reported in English cytological literature

Nephrogenic adenoma is a rare lesion of the urinary tract. The diagnosis usually is straightforward when characteristic microscopic and clinical findings are present, and the entity is familiar. However, misdiagnosis, in particular of adenocarcinoma of the prostate gland, may occur. Immunohistochemical stains often are needed to make such a distinction, but currently available markers offered only partial help. It recently was demonstrated that nephrogenic adenoma in renal transplant patients originated from the renal tubular epithelium. This newly proved, but long sought information may be helpful in the differential diagnosis of neophrogenic adenoma. In this study, we investigated the expression of a renal transcription factor, PAX2, in 39 nonrenal transplant-related nephrogenic adenomas, 100 adenocarcinomas of the prostate gland, and 47 urothelial carcinomas of the urinary tract. A strong and distinct nuclear staining of PAX2 was found in all 39 cases of nephrogenic adenoma (100%), but not in normal prostate tissue, normal urothelium, adenocarcinomas of the prostate gland, and invasive urothelial carcinomas. Focal CD10 was detected in six of 13 nephrogenic adenomas in the superficial papillary component and in normal prostate epithelium, normal urothelium, lymphocytes, adenocarcinoma of the prostate gland, and urothelial carcinoma. There was no uroplakins detected in nephrogenic adenoma. Therefore, these findings are suggesting that nephrogenic adenoma in nonrenal transplant patients may also arise from the renal epithelium, as did the comparable lesions after transplantation. PAX2 is a specific and sensitive immunohistochemical marker in identification and differential diagnosis of nephrogenic adenoma.Modern Pathology advance online publication, 6 January 2006; doi:10.1038/modpathol.3800535

BACKGROUND: An elevated CD4/CD8 T-cell ratio on flow cytometry (FCM) analysis has been reported in the literature to be associated with Hodgkin lymphoma (HL). The purpose of our study was to determine the diagnostic significance of an elevated CD4/CD8 ratio in lymph node fine needle aspiration (FNA) specimens. DESIGN: Between 1996 and 2002, out of 837 lymph node FNAs submitted for flow cytometry analysis, 85 cases showed an elevated CD4/CD8 ratio, defined as greater than or equal to 4, without definitive evidence of a lymphoproliferative disorder. The cytologic diagnoses of these 85 cases were grouped into four categories: reactive, atypical, Hodgkin lymphoma (HL), and non-Hodgkin lymphoma (NHL). Histologic follow-up was available in 17/85 (20%) of the cases. RESULTS: 5 of the 64 cases in which FCM and cytology did not reveal evidence of a lymphoproliferative disease had tissue follow-up because of persistent lymphadenopathy and high clinical suspicion. 3/5 (60%) confirmed the diagnosis of reactive lymphadenopathy. The two remaining cases (40%) were positive for lymphoma (1HL, 1NHL). 8/15 cases called atypical on cytology had histologic follow-up. 7/8 (87.5%) cases were positive for lymphoma (3HL, 4NHL). 3/4 cases called HL on cytology had tissue follow-up and all 3 (100%) confirmed the diagnosis of HL. One case diagnosed as NHL on cytology was found to be a diffuse large B-cell lymphoma. In summary, out of 17 cases with histologic follow-up 4/17 (24%) were reactive with CD4/CD8 T-cell ratio of 4.1-29, 7/17 (41%) were HLs with CD4/CD8 T-cell ratio of 5.3-11, and 6/17 (35%) were NHLs with CD4/CD8 T-cell ratio of 4.2-14. CONCLUSION: An elevated CD4/CD8 ratio on FCM is a nonspecific finding which may be seen in both reactive and lymphoproliferative disorders. The cytomorphologic features of the smear are more relevant than the sole flow cytometric finding of an elevated CD4/CD8 ratio

Fascin-1 is an actin-bundling protein that plays an important role in cell motility and adhesion. The level of fascin-1 is low or undetectable in normal epithelial cells. However, overexpression is reported in transformed epithelial cells and in several common types of carcinomas [Bioessays. 2002;24:359-361]. Up-regulation of fascin-1 is associated with higher grades and with aggressive tumors with poorer prognoses. We found no report on the role or the protein expression of fascin-1 in urothelial carcinomas (UCs) of the urinary bladder. In this study, we examined by immunohistochemistry the expression of fascin-1 in the normal human transitional epithelium, benign vesical lesions, and different types of UCs. We found no detectable fascin-1 in the normal transitional epithelium. There was no increase of fascin-1 expression in cystitis cystica, cystitis glandularis, nephrogenic adenoma (n = 10), inverted papilloma (n = 5), and classic exophytic papilloma (n = 4) or in adjacent transitional epithelia associated with these conditions. Patchy or diffusely weak fascin-1 expression was observed in 42% (5/12) of superficial papillary UCs (Ta), and 95% (19/20) of invasive UCs (T2 or higher) demonstrated diffuse strong staining for fascin-1. The microinvasive foci in the lamina propria of UC (T1, n = 8) were also positive for fascin-1, although they were not as strongly stained as in the deeply invasive tumors. Interestingly, the neoplastic cells in the tips of microinvasive carcinomas were distinctly positive for fascin-1. There were significant numbers of fascin-1-positive cells (>50% of the neoplastic cells) in UCs in situ (n = 10). These findings suggest an association between increased fascin-1 expression and increased invasiveness of carcinomas in the urinary bladder

A 48-yr-old black woman with a history of blood transfusions for menorrhagia secondary to uterine fibroids but no known Caribbean association presented with a 6-wk history of a rapidly enlarging right parotid mass. At the time of presentation, she could not close her right eye. An aspiration biopsy showed small, medium, and large lymphoma cells with angulated nuclei, red macronucleoli, and basophilic cytoplasm with fine vacuoles. Flow cytometry indicated a (CD25(+)/CD7(-)) T-cell lineage, suggesting an human T-lymphotropic virus (HTLV) 1-related T-cell leukemia/lymphoma, which was confirmed by polymerase chain reaction (PCR)-based amplification on DNA extracted from fresh tissue with specific oligonucleotide primers for HTLV-1 DNA sequence. Histology showed interstitial infiltration and destruction of the parotid parenchyma by lymphoma cells without involvement of adjacent lymph nodes. Total body CT scan and magnetic resonance imaging (MRI) studies were negative for lymphadenopathy but showed liver metastasis. To our knowledge, this is the first reported case of HTLV-1-related primary parotid lymphoma as the initial presentation of adult T-cell leukemia/lymphoma. Diagn. Cytopathol. 2004;31:333-337. (c) 2004 Wiley-Liss, Inc