Pathologic quiz case: a 15-year-old adolescent girl with supraclavicular lymphadenopathy and pleural and pericardial effusions.
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Adolescent↗
Biomedical subjects
Syed Z Ali
Publications and source records attributed to Syed Z Ali.
Pathologic quiz case: a 54-year-old man with hypertension. Primary high-grade leiomyosarcoma of the IVC.
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Humans↗
Hepatoblastoma: cytomorphologic characteristics in serious cavity fluids.
BACKGROUND: Hepatoblastoma (HBL) represents the most common primary hepatic tumor in children. Although the cytologic features of this tumor have been amply elucidated on fine-needle aspiration, exfoliative cytomorphologic characteristics have not been reported. The authors reviewed the cytopathologic features of six serous cavity fluids (SCF) from four patients with histologically proven HBL. METHODS: Five of the specimens evaluated were peritoneal fluids, and one specimen was pleural fluid from a patient with suspected pulmonary metastasis. Slides were prepared by cytocentrifugation and stained with Diff-Quik and Papanicolaou stains. The cytomorphologic features of each specimen were characterized, subclassified, and correlated histopathologically. RESULTS: All specimens showed hypercellular smears in a relatively clean background. Mixed embryonal and fetal subtypes of HBL disclosed three-dimensional clusters of neoplastic cells that formed straight or branched cords and acinus-like structures. The cells were moderately pleomorphic and had high nuclear-to-cytoplasmic (N/C) ratios. Occasional cells had eccentrically placed nuclei and vacuolated cytoplasm. Numerous mitotic figures were present. Rare intranuclear inclusions were noted. The anaplastic (small cell) subtype of HBL showed tight clusters of small, round, primitive cells with hyperchromatic nuclei, high N/C ratios, and prominent nuclear molding. In addition, there were numerous single cells with naked nuclei, often in an Indian-file configuration. Bile pigment, osteoid, and other mesenchymal components were absent in all specimens. CONCLUSIONS: The cytomorphologic features of HBL in SCF are quite characteristic. Although the differential diagnosis includes other childhood small, round, blue cell tumors and hepatocellular carcinoma, the above findings in the appropriate clinical-radiologic setting warrant a diagnosis of HBL.
Ascitic Fluid↗
Micropapillary serous carcinoma of the ovary: cytomorphologic characteristics in peritoneal/pelvic washings.
BACKGROUND: Micropapillary serous carcinoma (MPSC), a recently described entity, is an ovarian tumor with a distinctive histologic architecture that lacks a destructive infiltrative growth pattern and behaves like a low-grade neoplasm. The purpose of this study was to determine if specific cytomorphologic features were associated with this tumor in peritoneal/ pelvic washings. METHODS: Eight cases of MPSC were retrieved from the cytopathology files at The Johns Hopkins Hospital. Patients ranged in age from 31 to 74 years (mean, 58 years). A cytomorphologic comparison was made with pelvic washings of eight cases of papillary serous carcinoma (PSC) of the ovary. RESULTS: MPSC demonstrated small but well formed papillary fragments (generally < 30 cells) composed of monotonous, relatively small epithelial cells, often with multiple nucleoli. Single, large atypical cells were seldom present and were seen in less than one half of cases. Cellularity was generally high and slide background was clear with minimal inflammatory cells. In comparison, PSC, in addition to the smaller papillary fragments, also exhibited larger more complex papillary fragments (generally > 30 cells) composed of pleomorphic, hyperchromatic cells often with single prominent nucleoli. Single, large tumor cells exhibiting eccentric atypical nuclei or multinucleation were present in high concentration in the majority of PSCs. Psammoma bodies were observed in one half of cases in both tumor types. CONCLUSIONS: Although MPSC shares cytomorphologic similarities with PSC, it can be diagnosed adequately in peritoneal/ pelvic washings. Careful interpretation of the subtle cytologic differences seen in the two tumor types may facilitate the differentiation of these neoplasms for a more appropriate management of the patient.
Adult↗
Impact of SYT-SSX fusion type on the clinical behavior of synovial sarcoma: a multi-institutional retrospective study of 243 patients.
Synovial sarcomas are aggressive spindle cell sarcomas containing in some cases areas of epithelial differentiation. They consistently show a specific t(X;18;p11;q11), which usually represents either of two gene fusions, SYT-SSX1 or SYT-SSX2, encoding putative transcriptional proteins differing at 13 amino acid positions. Previous studies have suggested that patients with SYT-SSX2 tumors do better than those with SYT-SSX1 tumors, but the study groups were too limited to be conclusive. To address this issue more definitively, we collected data on SYT-SSX fusion type, pathology, and clinical course in a retrospective multi-institutional study of 243 patients (age range, 6-82) with synovial sarcoma. SYT-SSX1 and SYT-SSX2 fusions were detected in 147 tumors (61%) and 91 tumors (37%), respectively. Histologically, 61 (25%) were classified as biphasic type and 180 (74%) as monophasic type based on the presence or absence of areas of glandular epithelial differentiation, respectively. Median and 5-year overall survivals for the SYT-SSX1 and SYT-SSX2 groups were 6.1 years and 53%, and 13.7 years and 73%, respectively. Overall survival was significantly better among SYT-SSX2 cases (P = 0.03), among cases localized at diagnosis (P < 0.0001), and among patients with primary tumors < 5 cm in greatest dimension (P = 0.01). Age, sex, histological type, and axial versus peripheral primary site had no impact on overall survival. The impact of fusion type on survival remained significant when stratified for primary tumor size (P = 0.03) but was no longer significant when stratified for disease status at presentation. This may reflect the tendency for patients with SYT-SSX1 tumors to present more often with metastatic disease (P = 0.05). Cox regression identified disease status (P < 0.0001) and primary tumor size (P = 0.04) as the only factors independently predictive of overall survival in the subset of 160 patients with information on all of the factors. Within the subset of patients with localized disease at diagnosis (n = 202), the median and 5-year survival for the SYT-SSX1 and the SYT-SSX2 groups were 9.2 years and 61% versus 13.7 years and 77%, respectively. Patients whose tumors contained the SYT-SSX2 fusion (P = 0.08) or were smaller (P = 0.12) showed a trend toward better survival by log-rank test, whereas tumor histology had no impact (P = 0.8). In a Cox regression analysis considering all of the factors, SYT-SSX fusion type emerged as the only independent significant factor (P = 0.04) for overall survival within the subset of 133 patients with localized disease at diagnosis who had information on all of the factors. Among other comparisons, there was a strong association of fusion type and morphology (P < 0.001), with almost all of the SYT-SSX2 tumors showing absence of glandular differentiation (monophasic histology) and almost all of the biphasic tumors containing SYT-SSX1. There was also a statistically significant association of fusion type and patient sex (P = 0.03); specifically, the male:female ratio of SYT-SSX1 cases was 1:1, whereas for SYT-SSX2 cases, it was close to 1:2. Overall, SYT-SSX fusion type appears to be the single most significant prognostic factor by multivariate analysis in patients with localized disease at diagnosis. SYT-SSX fusion type also appears to exert part of its impact on prognosis before presentation through its association with stage at diagnosis. In addition, the associations of SYT-SSX fusion type with patient sex and tumor epithelial differentiation point to interesting mechanistic biological differences.
Adolescent↗
Endometrial-type cells in cervico-vaginal smears: clinical significance and cytopathologic correlates.
This study assessed the significance of endometrial-type cells (ETC) in cervico-vaginal (CV) smears in patients 45 yr and older by evaluating quantitatively and qualitatively the relationship of ETC to subsequent endometrial pathology. In a 3-yr period (1997-1999) at the Johns Hopkins Cytopathology Laboratory, 1,162 CV smears with ETC were found in patients 45 yr and older. In all cases with positive follow-up by tissue biopsy/resection, i.e., endometrial hyperplasia (EHP) and endometrial adenocarcinoma (EACA), the CV smears were reevaluated and compared to the control group (i.e., patients with normal endometrial biopsies). The following cytologic characteristics were recorded: quantity of ETC, type of ETC (epithelial, stromal/histiocyte-type, or mixed), cellular atypism, presence of inflammation, smear background, and associated estrogen effect. Of the 1,162 patients with ETC, 432 cases (37%) had tissue follow-up as follows: EACA, 18 (4.2%); EHP, 20 (4.6%); leiomyomata, 17 (3.9%); endometrial polyp, 21 (4.9%); benign/within normal limits (WNL), 339 (78.5%); nondiagnostic, 17 (3.9%). Cytologic characteristics of ETC showed subtle but definite quantitative and qualitative differences in the major pathologic groups examined. All instances of cancers and hyperplasia occurred in postmenopausal (PM) women. Abnormal vaginal bleeding was the presenting complaint in 66.7% of EACA, 45% of EHP, and 28.6% of benign endometrium. ETC in PM CV smears are associated with significant endometrial lesions (carcinoma, hyperplasia) in less than 9% of the patients. It is concluded that the distinction between EACA and EHP can be difficult. The presence of a large number of ETC, predominantly of epithelial or a mixed (epithelial and stromal) type, is more often associated with EACA or EHP than with benign endometrium. The presence of cytologic atypia and/or diathesis is additionally helpful for the diagnosis of EACA.
Adenocarcinoma↗
Breast masses in males: multi-institutional experience on fine-needle aspiration.
Male breast masses are uncommon pathologic findings. They are rarely aspirated, resulting in limited cytopathologic experience. The following study describes the cytopathology of male breast lesions from data collected for a period of 10 yr from three large institutions. A total of 14,026 breast aspirations were performed of which 614 were from male patients. All cases were reviewed and correlated with the appropriate clinicopathologic follow-up. The FNA diagnoses were as follows: benign, 427 cases (gynecomastia 353, fat necrosis 21, miscellaneous 53); malignant, 32 cases (ductal carcinoma nos 15, metastatic tumors 17); and atypical/suspicious, 61 cases. Ninety-four cases were nondiagnostic due to scant cellularity. Male breast aspirates accounted for 4.3% of the total breast FNAs performed. The clinicopathologic follow-up in both the benign and malignant categories showed 100% correlation. The overall sensitivity was 95.3%, specificity was 100%, and diagnostic accuracy was 98%. A relatively high specimen unsatisfactory rate was seen (>15%). The commonest cytopathologic diagnosis was gynecomastia, followed by ductal carcinoma. Florid duct atypia in gynecomastia may mimic adenocarcinoma, necessitating a higher threshold for cytopathologic interpretation for malignancy in males.
Adolescent↗
Myxopapillary ependymoma: cytomorphologic characteristics and differential diagnosis.
Myxopapillary ependymoma (ME) is a rare tumor with a predilection for sacrococcygeal area of adults. We present the cytomorphology of one such case in a 21-yr-old man, diagnosed by fine-needle aspiration (FNA). The tumor disclosed biphasic morphology with nests and aggregates of epithelioid malignant cells as well as branching cords of myxohyaline material. Most noticeable was the presence of distinct hyaline globules surrounded by neoplastic cells. The differential diagnosis of ME includes chordoma, adenoid cystic carcinoma, mucinous adenocarcinoma, and germ cell tumor. An accurate preoperative diagnosis of ME on FNA can be achieved based on its distinctive cytomorphologic features.
Adenocarcinoma, Mucinous↗
Hepatocellular carcinoma-fibrolamellar variant: cytopathology of an unusual case.
The fibrolamellar variant of hepatocellular carcinoma (FL-HCC) is an uncommon visceral malignancy with a distinctly better prognosis. An accurate initial diagnosis, therefore, is essential for prognostic and therapeutic reasons. This case report describes the cytomorphology of an unusual case of FL-HCC in a 13-yr-old boy who was found to have a hepatic mass with prominent intraluminal growth pattern seen predominantly in the right hepatic duct. A diagnosis of FL-HCC was originally suspected on bile duct brushings obtained during endoscopic retrograde choleangiopancreaticogram (ERCP) and subsequently confirmed on fine-needle aspiration (FNA) and surgical resection of the hepatic tumor. The cytomorphologic profile of FL-HCC is distinctive in the right clinical setting, allowing an accurate preoperative identification of this malignancy on biliary brushing or FNA.
Adolescent↗
Colloid cyst of the third ventricle: cytomorphologic features on stereotactic fine-needle aspiration.
Stereotactic brain fine-needle aspiration (FNA) is a valuable diagnostic modality for evaluating space-occupying central nervous system disorders. Colloid cyst (CC) is a rare nonneoplastic lesion thought to arise from misplaced endodermal tissue in the anterosuperior portion of the third ventricle. This study summarizes cytomorphologic features of CC on FNA along with clinical, radiologic, and histopathologic correlation. Ten cases of CC of the third ventricle diagnosed on FNA were retrospectively reviewed for a period of 12 yr (1989-2000). Material was obtained under stereotactic radiologic guidance. Smears were stained with Diff-Quik and Papanicolaou stains and cell block sections with hematoxylin and eosin. The aspirates showed a characteristic sticky and viscous quality on gross examination. Smears showed abundant, amorphous, proteinaceous material with staining qualities similar to colloid aspirated from thyroid. This included a purplish, filmlike coating of the slide with occasional "cracking" artifact; thick, globular, eosinophilic fragments; and granular, ropelike, and somewhat viscous, mucinous material. Pathognomonic radiating hyphae-like structures were not seen. The cellular components varied from isolated cuboidal/columnar cells to large tissue fragments of glandular-type epithelium with focal ciliated border. Goblet cells were frequently identifiable, as were fragments of collagenous cyst wall. Stereotactic FNA of the CC of the third ventricle is an accurate and cost-effective diagnostic modality. Cytomorphology coupled with the radiologic features is sufficiently unique for the diagnosis of this rare pathologic entity.
Adult↗
Prostatic adenocarcinoma metastases mimicking small cell carcinoma on fine-needle aspiration.
Prostate adenocarcinoma (PA) is known to metastasize widely to bone, lung, lymph nodes, and other sites. We have observed a rare, although distinctive, neuroendocrine (NE) cytomorphology of metastatic PA on fine-needle aspiration (FNA) that mimics small cell carcinoma (SCC). From a total of 117 cases, eight cases of metastatic PA diagnosed on FNA showed cytomorphologic features indistinguishable from SCC. All specimens were reviewed, along with immunoperoxidase (IPOX) studies using prostate specific (PSA, PSAP) and NE markers (synaptophysin, chromogranin, etc.). The patients ranged in age from 51-68 (mean age = 63). The PSA levels at the time of FNA ranged from <0.1 to 2,892 ng/ml (normal postprostatectomy <0.2 ng/ml). Sites of FNA included liver (two), soft tissue (five), and lymph node (one). FNA was performed from 11 mo to 6 yr after the initial diagnosis of the primary tumor. All primary PA were of high Gleason grade ranging from 7-9. None of the primary PA showed neuroendocrine morphology. Cytomorphologic characteristics observed on FNA included predominantly single cells with occasional sheets or loose cell aggregates. A predominant NE nuclear morphology was evident (i.e., hyperchromasia, fine dusty chromatin, inconspicuous nucleoli, nuclear molding, chromatinic crush artifact, karyorrhexis, mitoses, etc.), with none of the tumors displaying glandular formation. Taken together, these features gave these metastases a cytomorphology indistinguishable from SCC. IPOX studies revealed PSA-positivity (5/7), PSAP-positivity (4/7), and only focal NE markers positivity (3/6). Metastatic prostate carcinoma may rarely mimic a SCC (6.8% in this study). This often necessitates further patient workup to identify the primary source for the patient's metastasis, particularly if the patient has multiple lesions. An accurate diagnosis of these lesions as PA metastases is essential for effective, timely treatment and therapeutic design.
Adenocarcinoma↗
CD10 facilitates the diagnosis of metastatic renal cell carcinoma from primary adrenal cortical neoplasm in adrenal fine-needle aspiration.
Renal cell carcinoma (RCC) frequently metastasizes or invades the adrenal gland. Metastatic RCC is often difficult to differentiate from primary adrenal cortical neoplasm (ACN) in an adrenal fine-needle aspiration (FNA). Recently, CD10 immunoreactivity was observed in more than 90% of RCC, but none in primary ACN. To facilitate the accurate diagnosis of metastatic RCC in adrenal FNA, we retrospectively studied the cytomorphology and CD10 immunohistochemistry in 20 cases of FNA specimens, including 10 cases of adrenal FNA (six cases of metastatic RCC and four cases of primary ACN) and 10 cases of primary RCC. Cytomorphologically, several overlapping features were observed between primary ACN and metastatic RCC, including: abundant clear cytoplasm, often with microvesicles, large nuclei with prominent nucleoli, bare nuclei, and prominent vascularity. Immunostaining for CD10 was positive in 9/10 cases of primary RCC, 5/6 cases of metastatic RCC in the adrenal gland, and 0/4 cases of primary ACN. Our study indicates that: 1) an accurate diagnosis of ACN in FNA specimens can often be difficult due to overlapping cytomorphologic features with RCC, and 2) CD10 immunostaining is helpful in separating metastatic RCC from a primary ACN and can reliably be performed on a cytologic sample.
Adenocarcinoma, Clear Cell↗
Acinic-cell carcinoma, papillary-cystic variant: a diagnostic dilemma in salivary gland aspiration.
Fine-needle aspiration (FNA) plays a pivotal role as the initial diagnostic modality of choice when dealing with salivary gland (SG) lesions. Due to the heterogeneous nature of most SG neoplasms, cytologic interpretation on FNA can be quite challenging. This is particularly valid when dealing with rare tumor types, such as the papillary-cystic variant of acinic-cell carcinoma (ACC-PCV), resulting in a high rate of false-negative cytologic diagnoses. Seven cases of ACC-PCV diagnosed on tissue resection with a prior FNA performed in cytology were studied. Material consisted of Diff-Quik and Papanicolaou stained cytologic smears, as well as hematoxylin-eosin stained cell block and histopathologic sections. In no case did the FNA performed prior to the surgical resection eventuate in a cytopathologic diagnosis of cancer. A retrospective morphologic review of the smears disclosed several characteristics common to all 7 cases, i.e., mostly tightly cohesive fragments of neoplastic epithelium seen as monolayered sheets or with a prominent papillary architecture, high nuclear:cytoplasmic ratio ductal-type epithelium, cystic material and degenerated cellular debris, histiocytes, cells with squamoid and metaplastic oncocytic changes, vacuolated and pigmented histiocyte-like tumor cells, and lack of a predominant single-cell component or naked neoplastic cell nuclei. ACC-PCV represents a rare yet significant cause of false-negative results for cancer on SG aspirations. An erroneous interpretation may occur due to lack of experience in dealing with this tumor type, the rarity of published literature on ACC-PCV, and a predominantly cystic, somewhat variegated appearance of the tumor mimicking other benign and malignant SG lesions.
Adenocarcinoma, Sebaceous↗
Reed-Sternberg-like cells in lymph node aspirates in the absence of Hodgkin's disease: pathologic significance and differential diagnosis.
We discuss nine cases identified at our institution with prominent Reed-Sternberg-like cells in fine-needle aspiration of lymph nodes in patients without Hodgkin's disease. Cytomorphology was studied using Diff-Quik and Papanicolaou-stained smears and flow cytometric analysis was performed in all cases. Clinical and/or histopathologic follow-up was reviewed. Of the nine cases, all were diagnosed as "atypical lymphoid proliferation" despite a negative flow cytometric analysis. Clinicopathologic follow-up revealed that three cases evolved into malignant non-Hodgkin's lymphoma and one case into a posttransplant lymphoproliferative disorder. The remaining five cases were benign in the follow-up period also, of which one case was later diagnosed as an inflammatory pseudotumor. In two cases of reactive hyperplasia and in the inflammatory pseudotumor case, an in situ hybridization stain for Epstein Barr virus (EBV) was positive. The significance and differential diagnosis of Reed-Sternberg-like cells in lymph nodes in the absence of Hodgkin's disease is discussed.
Adult↗
Detection of allelic imbalance in ascitic supernatant by digital single nucleotide polymorphism analysis.
PURPOSE: Cytological examination of ascitic fluid is critical for clinical management of patients with peritoneal or pelvic diseases. Such morphological examination can only achieve a sensitivity of <62%, and thus a molecular test that is able to distinguish benign versus malignant ascites could be clinically useful. In this study we determined the presence of allelic imbalance (AI) in tumor-released DNA in ascitic supernatant by directly counting the alleles using a newly developed technology, digital single nucleotide polymorphism (SNP) analysis. EXPERIMENTAL DESIGN: Allelic status was assessed using a total of seven SNP markers that commonly demonstrated AI in ovarian, colorectal, and pancreatic cancers. RESULTS: With digital SNP analysis, AI in at least one SNP marker was found in 19 of 20 (95%) ascitic fluid DNA samples obtained from patients with cytologically proven carcinomas in ascitic fluid. In contrast, AI was detected in only 1 of 20 patients with negative cytology. This latter patient with AI in her ascites had known stage III ovarian carcinoma at the time of cytology sampling. The ascitic specimen of this patient demonstrated the presence of carcinoma cells in culture with an identical AI pattern found in the ascitic supernatant and surgical specimen. CONCLUSIONS: These findings suggest that detection of AI using digital SNP analysis can be a useful adjunct for the detection of ovarian and other types of cancer in ascitic fluid.
Alleles↗
Myoepithelial carcinoma arising in a pleomorphic adenoma of the parotid gland: report of a case with cytopathologic findings.
BACKGROUND: Carcinoma arising in a mixed tumor, or carcinoma ex pleomorphic adenoma (CEPA), is an uncommon primary salivary gland neoplasm. Among the various types of carcinomas that can be seen histologically in a CEPA, myoepithelial carcinoma is one of the rarest forms. CASE: A 76-year-old woman presented with an incidental parotid/parapharyngeal mass. Computed tomography-guide fine needle aspiration (FNA) showed a biphasic neoplasm with epithelial and stromal components consistent with pleomorphic adenoma (PA). However, in addition, a distinct population of discohesive atypical and pleomorphic cells with high nuclear/cytoplasmic ratio was noted in the background. In the cytopathologic diagnosis a suspicion was raised about a possible CEPA. Subsequent resection of the parotid mass confirmed the presence of low grade myoepithelial carcinoma arising in a PA. CONCLUSION: Although uncommon, CEPA should be suspected on FNA when atypical cytomorphologic characteristics are observed. In rare cases a myoepithelial carcinoma also arises in a preexisting PA, necessitating an accurate interpretation for more definitive therapy.
Adenoma, Pleomorphic↗
Cytopathology of vertebral and paravertebral lesions.
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Biopsy, Fine-Needle↗
Impact of liquid-based gynecologic cytology on an HIV-positive population.
OBJECTIVE: To examine the imprint of liquid-based technologies for cervicovaginal cytology on HIV-positive women, who are at high risk for cervical intraepithelial neoplasia. STUDY DESIGN: We performed a retrospective search of the cytopathology files of Johns Hopkins Hospital for the cervicovaginal cytology of HIV-positive women to examine the effect of liquid-based technology on this population. RESULTS: Significant intraepithelial lesions (SILs) (low grade SIL or greater) were identified in 24% of the conventional smears and 23% of the liquid-based cytology. Atypical squamous cells of undetermined significance (ASCUS)/atypical glandular cells of undetermined significance was diagnosed in 15% of the conventional smears and 9% of the liquid-based preparations (P = .02). In patients with ASCUS diagnoses and tissue follow-up within 7 months, significant SILs were identified in 29% with conventional smears and in 65% with liquid-based cytology. CONCLUSION: There was no statistically significant difference in the rate of SILs between conventional smears and liquid-based cervicovaginal preparations in HIV-positive women. The diagnosis of ASCUS on liquid-based cytology may have an increased likelihood of representing a significant SIL in comparison to conventional smears. For the high-risk, HIV-positive population, immediate colposcopy and biopsy may be warranted following ASCUS diagnoses on liquid-based cytology.
Adult↗