Faculty Bibliography

Background: Urothelial carcinoma of the upper tract (UTUC) is relatively rare. Urine cytology has been used in the diagnosis and surveillance of UTUC but its utility is not well established. Another method of UTUC detection is via endoscopic biopsy which itself can be limited due to inadequate sampling. Our study aims to explore the efficacy of urine cytology alone and in combination with endoscopic biopsy results in detecting UTUC. Design: We searched our pathology database for cases with both urine cytology specimen and subsequent histologic followup including endoscopic biopsies, ureterectomy, nephrectomy or nephroureterectomy over a 10 year period. Urine cytology and biopsies done concurrently or within 6 months follow-up are included in the study and the highest degree of abnormality was selected if multiple specimen available. For cases with both biopsies and surgical specimen diagnoses, the final diagnosis from surgery was used. Results: 154 cases of confirmed UTUC were included in the study. Among them, urine diagnoses of suspicious or positive for malignancy were made in 106 cases (69%): 7 cases were low grade UC (LGUC) and 99 cases were high grade UC (HGUC) upon surgical pathology evaluation. 32/154 cases (21%) were atypical urothelial cells (AUC) on cytology, among which 27 had confirmed HGUC and 5 cases had LGUC on surgical pathology. 16/154 urine cytology cases (10%) were negative: 11/16 had HGUC and 5/16 cases had LGUC in the concurrent or follow-up biopsies or surgery. The sensitivity for abnormal urine cytology was 89.6% for detecting UTUC. We also compared the urine cytology and endoscopic biopsies (within 6 months) in detecting UTUC. There are 62 cases are positive for both methods. Four cases show positive urine but negative biopsy, and 1 with negative urine but positive biopsy (HGUC). The sensitivity for combined urine cytology and biopsy is slightly higher for one method alone. Conclusions: Urine cytology is highly sensitive for detecting UTUCespecially for HGUC. Combining urine cytology and endoscopic biopsy results increases the sensitivity for detecting UTUC and should therefore be recommended for clinical practice

Cytologic diagnosis of extra-adrenal paraganglioma presenting as a peripancreatic mass is challenging with a high error rate due to its rarity. We report two cases of peripancreatic masses identified by radiology. Endoscopic ultrasound-guided fine needle aspiration (FNA) of the masses showed a moderately cellular tumor composed of small to medium sized neoplastic cells with round to oval nuclei, arranged singly and in loose clusters. Focal rosette-like structures were present. The cells were positive for neuroendocrine markers (synaptophysin and chromogranin). A diagnosis of a neoplasm with neuroendocrine differentiation and neuroendocrine tumor was made respectively on FNA for each case. The subsequent surgical resection of the tumors revealed peripancreatic paraganglioma. Although paraganglioma has been reported in the literature, the detailed comparison of perpancreatic paraganglioma versus pancreatic/gastrointestinal neuroendocrine tumor is still lacking. Therefore using these two cases with literature review, we wish to illustrate the differential diagnosis between these two entities based on cytomorphology and immunohistochemical study.

Introduction: The success of cell block preparation is crucial for ancillary diagnostic tests in cytology. However, achieving an optimal cell block can be challenging. We observed that cell block cellularity is best in cases with visible blood clots in the fine-needle aspiration (FNA) needle wash solution. Therefore, we hypothesized that the adequacy of cell block preparation will improve if FNA aspirates are allowed to first form a clot in the collection tube. Materials and Methods: We created a modified cell block preparation technique allowing FNA samples to clot in a dry tube prior to addition of any liquid media or further cell block preparation (Figure 1). The clinical data, FNA procedure and the cellularity of cell blocks of the clotting group (37 cases) and the conventional needle wash group (33 cases) were compared. Cellularity was evaluated using a scoring system (0 = acellular, 1Z 10 - 50 cells, 2 = > 50 cells). Results: 28 cases (78%) received a score of 2 in the clotting group compared to 12 (36%) in the conventional needle wash group. 5 (15%) received a score of 1 in the clotting group compared to 3 (9%) in the conventional group; 4 received a score of 0 (11%) in the clotting group versus 18 (55%) in the conventional group. The difference in cell block cellularity between the two methods was statistically significant (p < 0.001) (Figure Presented) (Table 1). Immunohistochemistry (15 cases) and molecular analyses (2 cases) was performed in the clotting group compared to 10 and 1 case, respectively in the conventional group. Conclusions: Our study demonstrates that clotting method is superior to the conventional needle wash method. The clotting method avoids diluting FNA samples in liquid media and maximizes the collection of cellular material by holding the aspirate tightly in a blood clot

The detection of primary anorectal melanoma on anal cytology is a rare and challenging diagnosis. We report a case where anorectal cytology showed isolated malignant cells with oval nuclei, prominent nucleoli, and elongated wispy cytoplasmic projections. There was no evidence of squamous dysplasia or melanin pigment identified. To the best of our knowledge, this is the first reported case of a primary anorectal melanoma detected in anorectal cytology. Detection of malignancies other than squamous cell carcinoma can be seen on anorectal cytology and should be considered when there is no evidence of anal intraepithelial neoplasia. Diagn. Cytopathol. 2017. (c) 2017 Wiley Periodicals, Inc.

Sclerosing hemangioma of the lung is a benign neoplasm with a widely debated histogenesis. It has a polymorphic histomorphology characterized by a biphasic cell population of "surface cells" and "round cells" arranged in four general patterns: Papillary, solid, angiomatous, and sclerotic. This variability in histomorphology makes it difficult to diagnose sclerosing hemangioma by fine needle aspiration (FNA). We present a case of sclerosing hemangioma diagnosed on FNA with immunohistochemistry performed on an accompanied cell block. The clinical presentation, cytomorphology, immunohistochemistry, and differential diagnoses are discussed.

Introduction: Ultrasound guided FNA is important in guiding management of thyroid nodules. Complications are usually limited to localized discomfort, bruising, or minor hematomas. At our institution, cytopathologists perform 600 - 900 ultrasound guided thyroid FNAs yearly. Acute transient thyroid swelling is a rare complication. A diffuse swelling of the entire thyroid occurs after a biopsy with a characteristic "cracked appearance" on ultrasound imaging. Cytopathologists and radiologists need to recognize this phenomenon and terminate the procedure. Materials and Methods: We conducted a retrospective review of our pathology and radiology database from 2004 -2015 for documented transient thyroid swelling. We reviewed patient demographic information, thyroid antibody and function studies, allergies/ medical history, and pathology diagnosis (Table 1). Results: We identified 7 cases of transient diffuse swelling of the thyroid from 6,175 thyroid FNAs. In all cases, the thyroid architecture becomes obscured by diffuse enlargement of the thyroid with an internal "cracked appearance" without skin swelling or hematoma (Figure 1). Imaging shows two to three times increase in overall thyroid volume. Patients usually reported acute pain that resolved shortly after the procedure was ceased and ice pack was applied. Post-procedural observation showed resolution of swelling. Patients had no known latex allergy or prior adverse reactions to needles. In most cases, the patients tolerated initial FNA without complications. One patient had a repeat FNA with Benadryl premedication without adverse complications but it is unclear whether there was a preventative effect. Conclusion: This benign, transient reaction should be distinguished from severe complications such as anaphylaxis and hemorrhage. We hypothesize that this event is attributable to intra-thyroidal edema since no discrete hematoma is seen on imaging. Pre- and post-procedural ultrasound imaging is essential for detecting change in thyroid architecture. Recognition of this rare event is crucial when performing ultrasound guided thyroid FNA. (Figure Presented)

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