Faculty Bibliography

Amyloidomas are rare tumors composed of deposits of amyloid protein not associated with systemic amyloidosis. They can present as an initial manifestation of a systemic disease process or can be a completely localized phenomenon. We present a case of amyloidoma associated with insulin injection site found incidentally in an 80-year-old male with multiple co-morbidities who presented with diverticulitis associated bleeding. A subcutaneous abdominal mass was found on physical examination. Imaging revealed a 5 cm x 1.6 cm homogenous subcutaneous lesion. A fine-needle aspiration (FNA) and core biopsy were performed under ultrasound guidance to reveal amorphous material proven to be amyloidosis at insulin injection sites (AIns) type amyloid. The patient had no treatment for this lesion and has had his care triaged to his more serious health problems. This is the first case of AIns type amyloidoma associated with insulin injection site reported in cytology literature. We highlight the cytologic findings and diagnostic pitfalls. As the incidence of diabetes is increasing, cytopathologists may encounter this lesion more often on FNA.

Celebratory gunfire injuries from "falling bullets" occur when guns are fired into the air during celebrations without realizing that this can cause serious injuries or even fatalities. Fatal celebratory gunfire injury is an uncommonly reported event in the continental United States. Our electronic database was queried for homicides occurring within days of July 4th and December 31st over a 14-year period. We describe two cases of fatal gunfire injury due to celebratory gunfire occurring during New Year's Eve in Southern Florida. The relevant literature is reviewed. These case reports illustrate that fatal gunfire injuries sustained from "falling bullets" may pose as an unexpected mimic to sudden natural deaths especially in patients with prior medical history. A high index of suspicion to recognize such injury is required particularly during holidays.

Anaplastic lymphoma kinase protein (ALK)-negative anaplastic large cell lymphoma (ALCL) has a vast morphologic spectrum and may mimic many other types of malignancies both cytologically and histologically. There are only a few published case reports/series describing the cytomorphologic features of ALCL on fine-needle aspiration (FNA) biopsy specimens. We describe a case of ALK-negative ALCL mimicking a high-grade soft tissue sarcoma of the thigh in a 62-year-old man. The characteristic morphologic findings on FNA and core biopsy along with the immunophenotypic profile are described and reviewed. The diagnosis of ALCL on FNA biopsy may be difficult, but can be done successfully with the use of ancillary tests. Therefore, it must be considered in the differential diagnosis of lesions with pleomorphism, anaplasia, and wreath-like or horseshoe-shaped nuclei to ensure that adequate material is obtained for ancillary studies

Liquid silicon used for soft tissue augmentation can produce different histologic patterns when implanted into the dermis or subcutis, depending on the degree of purification and the injected volume. The pure medical-grade silicon implanted in miniscule amounts in a controlled manner results in minimal fibroplasia without significant inflammation. The industrial-grade silicon contaminated by additives may remain dormant for years and eventually cause formation of extensive granulomas and disfiguring nodules. We report a case of a 35-year-old transsexual woman who presented with bilateral buttock masses. Histologic evaluation revealed collections of cells with lipid-containing cytoplasmic vacuoles resembling lipoblasts. This pattern can be clinically and histologically confusing for a neoplastic process, particularly when this adverse effect of adulterated silicon develops years after the injection.

An increased incidence of neoplasia was recently reported in patients with familial dysautonomia. This suggests that, in addition to its role in neuronal development, the IKBKAP gene may also influence DNA repair. Here we report the case of a 28-year-old male with familial dysautonomia who was found to have neoplastic lesions detected post mortem as incidental findings. This case indicates that the prevalence of tumorgenesis within this population may be underestimated.

Background. The hepatitis C virus is a major cause of hepatocellular carcinoma. Extrahepatic manifestations of hepatitis C include mixed cryoglobulinemia which can result in ischemic damage to multiple organs. The management of these sequelae in posthepatectomy patients is unclear. Case Report. A 49-year-old male with hepatitis C was found to have a 4 cm hepatocellular carcinoma on surveillance imaging. He underwent portal vein embolization followed by hepatectomy. His postoperative course was complicated by the development of splenic infarcts, small bowel ischemia, skin lesions, and liver damage. Findings of elevated cryocrit and elevated rheumatoid factor suggested the diagnosis of cryoglobulin-related vasculitis. The patient improved on supportive care. Conclusion. Cryoglobulinemia is associated with hepatitis C and may complicate the care of this patient population. The treatment of cryoglobulinemia posthepatectomy patients is complicated by concerns over how medications may affect the regenerating liver. Steroids should be used with caution in this setting. Summary. Brief report of hepatectomy complicated by vasculitis in the context of hepatocellular carcinoma secondary to hepatitis C addresses the management of mixed cryoglobulinemia in post-hepatectomy patients

BACKGROUND: Anaplastic thyroid carcinoma (ATC) is rare but is one of the most aggressive and lethal human malignancies. Cytologically, ATC has a variable morphologic appearance, including squamoid, giant, spindled and pleomorphic cells. The coexistence of ATC and differentiated or poorly differentiated thyroid carcinoma has been described and usually is diagnosed when the disease is locally advanced. CASE: We describe a case of surgically resectable, encapsulated, well-circumscribed ATC occurring in association with a better differentiated follicular carcinoma diagnosed by fine needle aspiration in a patient exposed to external ionizing radiation. CONCLUSION: Encapsulated variants of anaplastic carcinoma can be seen in association with lower grade thyroid carcinoma such as follicular carcinoma. Accurate diagnosis is dependent on adequate sampling

Over the past decade, core biopsy rapidly replaced fine needle aspiration (FNA) in evaluation of diseases of the female breast in many centers in the USA. The inability to diagnose invasive cancer by FNA, and the general feeling of unease in interpretation of cytologic specimens among pathologists who are not trained in cytopathology are among factors leading to decline in the use of FNA. At our institution, we continue to rely heavily on FNA for evaluation of breast masses. In this article, we discuss our multidisciplinary team approach which is essential in sustaining a successful breast cancer screening program. We also review the general utility of breast FNA and core biopsy in a comparative fashion. In the second part of this article which will appear in an upcoming issue, we will review the use of FNA and core biopsy in challenging breast lesions focusing on the pitfalls and limitations of both modalities in selected specific lesions

Androgen deprivation therapy induces apoptosis and decreases both cell proliferation and angiogenesis in prostate adenocarcinoma. The molecular alterations following androgen ablation translate into unique cytologic features in both primary and metastatic prostate adenocarcinoma. We describe the cytologic appearance of metastatic prostate carcinoma following both surgical castration and androgen deprivation therapy

BACKGROUND: The cytomorphology of anaplastic large cell lymphoma (ALCL) is distinctive yet variable. To the authors' knowledge, to date only small case series have described the cytologic findings noted in patients with ALCL. The current series is the largest case series presented to date to retrospectively review the cytomorpholgic findings noted in patients with ALCL, with specific attention paid to those with anaplastic lymphoma kinase (ALK)-negative ALCL. METHODS: Over a 13-year period, the available Diff-Quik cytology smears and surgical excision specimens taken from patients with ALCL were evaluated. Different clinical and morphologic parameters were evaluated, including ALK status. RESULTS: A total of 37 cases were retrieved and evaluated, 19 of which had both cytology and surgical pathology specimens available for review. ALK-negative ALCL cytology smears were found to have a high number of anaplastic cells compared with ALK-positive cases. The hallmark cells in the ALK-negative cases were not classic. CONCLUSIONS: ALCL can be diagnosed accurately by fine-needle aspiration cytology (FNAC) alone when aided by immunocytochemistry in ALK-positive cases. Ancillary studies should be anticipated such that material for cell block preparation and molecular studies is taken at the time of FNAC. The results of the current study demonstrate the varied FNAC morphology of ALCL. The presence of severe pleomorphism and anaplasia was found to correlate with ALK-negative status