A case of metastatic breast cancer with outgrowth of HER2-negative cells after eradication of HER2-positive cells by humanized anti-HER2 monoclonal antibody (trastuzumab) combined with docetaxel

A 38-year-old woman with cancer of the left breast underwent a modified radical mastectomy with lymph node dissection. Twenty-one months later, massive liver metastases and pleural carcinomatosis occurred. The liver metastases responded completely to chemotherapy with trastuzumab combined with docetaxel, but the pleural carcinomatosis was refractory to the therapy. Fluorescence in situ hybridization showed that both the primary tumor and the metastatic tumors of the lymph nodes were composed of HER2 amplification-positive and HER2 amplification-negative cancer cells. This analysis also detected a single cell with HER2 amplification in the pleural effusion that was taken at the completion of the chemotherapy, but four follow-up tests showed no amplified cells. It is speculated that in the liver metastases, the trastuzumab was cytotoxic to both HER2-amplified and nonamplified cancer cells and may have acted through its antiangiogenic effect. However, in the pleural effusion, the effect of trastuzumab was more specific to HER2-amplified cells and caused outgrowth of cancer cells lacking expression of HER2 receptors.     

Fractal dimension of cell clusters in effusion cytology

In this study, the fractal dimension (FD) of the ball‐like tight clusters of known metastatic adenocarcinoma cells is compared with the tight cell clusters of the benign cells in the effusion fluid to find out the role of FD in differentiating malignant from benign cluster in effusion. A total of 68 and 72 images of cluster of cells from 12 cases of benign and 13 cases of metastatic pleural and peritoneal effusion were studied for FD. The mean FD of the cluster of cells of benign and malignant effusion was 1.4801 ± 0.23260 and 1.7175 ± 0.09006, respectively. Mann–Whitney U‐test showed significant difference of FD between the cell clusters of malignant and benign effusion cases (P < 0.0001). Cytological features along with the measurement of FD of cell clusters in effusion cytology may be helpful in differentiating benign from malignant cases. Diagn. Cytopathol. 2010;38:866–868. © 2010 Wiley‐Liss, Inc.     

Disseminated thymoma in pleural fluid: An unusual case

Thymic epithelial tumours show characteristic cytological features on fine-needle aspiration cytology, however the cytological features of thymoma in fluid cytology are not well described. We present the case of a 77 year-old-woman with known pleural dissemination of type B2/B3 thymoma presenting with shortness of breath and orthopnoea due to a pleural effusion. Cytological evaluation of the pleural fluid showed cellular smears composed of numerous small lymphocytes with small numbers of admixed mesothelial cells. There was no epithelial component. On immunohistochemical (IHC) staining the lymphocytes were T cells which were positive for CD3. CD1a and terminal deoxynucleotide transferase (TdT) were also positive, consistent with immature lymphocytes of thymic origin. Despite the lack of an epithelial component, this case was diagnosed as suspicious for recurrent/ metastatic thymoma. This is only the second published case of thymoma identified on pleural fluid cytology, and to our knowledge the first case describing thymoma in pleural fluid with no epithelial component, a potential pitfall with the more common differential diagnosis of a reactive lymphocytic effusion.     

Metastatic upper tract urothelial carcinoma with nest-like features presenting as malignant pleural effusion

Metastatic urothelial carcinoma is a rare cause of pleural effusions. We report a case of urothelial carcinoma of the upper urinary tract in an oldest-old male patient, a smoker, with situs inversus totalis, that presented uniquely with malignant pleural effusion at presentation without evidence of a primary tumor on imaging. Cytological smears of the massive left pleural effusion revealed epithelioid neoplastic cells arranged in short cords, small-to-large clusters, and raspberry-like morules, mimicking mesothelioma; cell block preparations highlighted the presence of tubules and nest-like structures. The tumor cells showed a high nuclear-to-cytoplasmic ratio, nuclear grooves, and mitotic figures. Cytomorphologic features coupled with the immunophenotype of neoplastic cells (p63, GATA3, and uroplakin II positive) allowed the diagnosis of metastatic urothelial carcinoma and a possible nested subtype. These findings were supported by a total body computed tomography (CT) showing no evidence of a mass in the bladder or elsewhere in the urinary tract but a concentric parietal thickening of the proximal left ureter, suggesting malignancy. To our knowledge, a malignant effusion as a primary manifestation of urothelial carcinoma with nest-like features originating in the upper urinary tract has never been described previously. Our case focuses on the value of cell block in the working-up of neoplastic effusions by revealing the architectural pattern of an uncommon malignancy and the correlation between cytopathology and imaging gross findings to reach an accurate diagnosis.     

Myxofibrosarcoma of the heart: A case report with positive pleural effusion cytology

Primary cardiac sarcoma is rare, and there have been only a few reports on its cytologic findings. Myxofibrosarcoma, a variant of fibrosarcoma of the heart, is an extremely rare entity. We present a case of primary cardiac myxofibrosarcoma in a 63‐year‐old woman. Pleural fluid cytology and imprint cytology of the resected tumor at operation and autopsy were obtained. Cytologic evaluation with immunocytochemical staining utilizing a cell transfer technique revealed that tumor cells of the resected tumor and autopsy specimen and pleural effusion demonstrated large and pleomorphic cells with irregular, hyperchromatic nuclei and were positive for vimentin. Combination of morphology and immunoprofile of the cells of pleural effusion was compatible with the diagnosis of metastatic myxofibrosarcoma. Diagn. Cytopathol. 2016;44:1112–1116. © 2016 Wiley Periodicals, Inc.     

Extra-salivary gland presentations of adenoid cystic carcinoma: a report of three cases

Adenoid cystic carcinoma (ACC) is a malignant neoplasm most commonly originating in salivary glands of the head and neck area. When ACC presents outside of these locations, the diagnosis may become more challenging. We describe three cases of ACC presenting in extra-salivary gland sites. Two cases were metastatic; in case 1 the initial presentation was widespread bony metastasis of unknown primary origin. The other metastatic case (case 2) was from a patient presenting with a pleural effusion and a history of previously treated metastatic pulmonary ACC. The pleural effusion cytology was unusual in that exfoliated ACC cells were present in the effusion itself, a rare occurrence. Case 3 was a primary bronchial ACC. In conclusion, ACC can present in various body sites and cytologists must consider this neoplasm when presented with a basaloid carcinoma of uncertain origin.     

Comparison of intratumoral heterogeneity of HER2 expression between primary tumor and multiple organ metastases in gastric cancer: Clinicopathological study of three autopsy cases and one resected case

Intratumoral heterogeneity of HER2 expression in the metastatic foci of HER2‐positive advanced gastric cancer remains unclear. In this study, we compared HER2 expression between primary and metastatic tumors in HER2–positive three autopsied cases and one resected case with multiple organ metastases by immunohistochemistry (IHC) and dual color in situ hybridization (DISH). All four cases judged positive (IHC3+) at the primary tumor tissues showed varying HER2 gene amplification (GA) status. One homogeneously HER2‐positive autopsied case (Case 1) and one intratumorally heterogeneous positive resected case (Case 2) with high GA showed a homogeneous positive staining pattern in all the metastatic foci. One heterogeneously HER2‐positive autopsied case (Case 3) with low GA showed a partially heterogeneous HER2 staining pattern in all the metastatic foci. In contrast, one heterogeneously HER2‐positive autopsied case (Case 4) with equivocal GA showed a completely heterogeneous HER2 staining pattern in the metastatic foci. These results indicate that HER2‐positive gastric cancers with low to high GA at the primary tumor show substantially homogeneous HER2 overexpression in the metastatic foci, whereas HER2‐positive gastric cancers with equivocal GA expressed HER2 heterogeneously within the metastatic tumor, suggesting that metastatic foci of the latter HER2‐positive cases would be potentially resistant to trastuzumab.     

Cytologic features of ovarian granulosa cell tumors in pleural and ascitic fluids

Adult granulosa cell tumor (AGCT) is an uncommon neoplasm of the ovary with potential for aggressive behavior and late recurrence. The most important prognostic factor for AGCT is tumor stage. Thus, cytological assessment of pleural or ascitic fluids is crucial for initial staging and subsequent patient management. We report herein two cases of ovarian AGCT presenting with exfoliated tumor cells in pleural and ascitic fluid. The first case involved a 61‐year‐old woman who presented with stage Ic (a) AGCT. Seven years after initial diagnosis, pleural effusion and pleural dissemination were identified. The second case involved a 50‐year‐old woman who presented with stage IV AGCT with massive ascites and right pleural effusion. Fluid cytology from both cases showed cohesive or loose clusters of small uniform neoplastic cells with round‐to‐oval nuclei, coffee‐bean‐shaped nuclear grooves, small nucleoli, and scant cytoplasm. Call‐Exner bodies were also observed in these cytologic specimens. In the differential diagnosis of small monomorphic tumor cells in pleural effusion or ascites, coffee‐bean‐shaped nuclear grooves and cell clusters forming Call‐Exner bodies are diagnostic clues of AGCT. Diagn. Cytopathol. 2015;43:581–584. © 2015 Wiley Periodicals, Inc.     

Intratumoral heterogeneity of HER2 protein and amplification of HER2 gene in salivary duct carcinoma

Salivary duct carcinoma (SDC) is an aggressive adenocarcinoma of the salivary glands, and accounts for 1–3% of all malignant salivary gland tumors, resembling morphologically invasive ductal carcinoma (IDC) of the breast. In contrast to IDC of the breast and gastric carcinoma (GC), the study of human epidermal growth factor receptor 2 (HER2) in SDC has not progressed. Therefore, we investigated the relationship between HER2 protein expression and amplification of the HER2 gene, and compared them in terms of intratumoral heterogeneity (ITH) in 13 cases of SDC using immunohistochemistry and dual color in situ hybridization. We found seven cases with protein overexpression (53.8%) and five cases with gene amplification (38.5%) in accordance with ASCO/CAP guidelines. ITH of HER2 protein expression was seen in seven cases (53.8%). Interestingly, the ratio of the HER2 gene showed homogenous distribution with or without the presence of ITH of HER2 protein expression. SDC tends to have more ITH of HER2 protein similarly to GC, in contrast to IDC of the breast. ITH of HER2 protein in SDC has no heterogeneity of the HER2 gene amplification. The mechanism of HER2 protein expression in SDC might proceed through a more complex pathway relative to that of IDC of the breast.     

Fine‐needle aspiration biopsy of pleural metastases from a carcinosarcoma or true malignant mixed tumor of the parotid gland mimicking a mesothelioma

Malignant mixed tumor of the parotid is known to have odd sites for metastases. We describe the fine‐needle aspiration cytology (FNAC) findings of pleural metastasis from a malignant mixed tumor misdiagnosed as a mesothelioma on cytology at the onset. A 47‐year‐old man presented to us with breathlessness and a massive pleural effusion with pleural‐based nodules. He had been operated 2 years before for a pleomorphic adenoma of the parotid and had a healthy scar at that site. FNAC from the pleural lesions showed myxoid background substance with entrapped cuboidal epithelial cells with atypical nuclei, which were interpreted as mesothelial cells. These cells in contrast to the usual mesothelial cells were not arranged in sheets but rather were huddled in places and formed a pseudoacinar pattern and blended with the myxoid substance. After the diagnosis of a mesothelioma, patient received pemetrexed and cisplatin based chemotherapy with partial response. While on chemotherapy tumor recurred at the primary site in parotid and was confirmed to be a carcinosarcoma on a FNAC and biopsy. To conclude, pleural metastases from a true malignant mixed tumor of the parotid gland can be misdiagnosed as mesothelioma and could occur in the absence of uncontrolled disease at primary site. Both mesotheliomas and pleomorphic adenomas metastatic to the pleura are biphasic tumors, but in a patient with history of pleomorphic adenoma, the latter should be kept as a foremost possibility. Attention to the cytomorphology of tumor cells will also assist in confirming the diagnosis. Diagn. Cytopathol. 2009. © 2009 Wiley‐Liss, Inc.     

A metastatic renal carcinoid tumor presenting as breast mass: a diagnostic dilemma

We present clinicopathological and cytological findings of a well-defined breast mass in a patient with history of primary renal carcinoid tumor. Fine-needle aspiration (FNA) cytology showed monotonous tumor cells with plasmacytoid appearance arranged singly and in small clusters. Occasional tumor cells were arranged in acinar architecture resembling glandular differentiation. Tumor cells showed fine speckled chromatin. The unusual location for metastasis of this rare type of carcinoid tumor and overlapping cytological features with primary mammary carcinoma led to an erroneous preliminary cytological diagnosis of primary breast carcinoma with plasmacytoid features. Tumor cells in the corresponding cell block showed strong diffuse positivity for synapthophysin and pan-cytokeratin with weak focal positivity for chromogranin markers. These patterns of immunostaining were similar to the original renal carcinoid tumor. To the best of our knowledge, a few cases of carcinoid tumor metastatic to the breast have been reported in the literature and more than half of these cases were initially misdiagnosed as primary breast carcinoma causing unnecessary surgical treatment. This is a first reported case of metastatic renal carcinoid tumor into breast diagnosed with FNA biopsy. This report highlights the cytological features of well-differentiated neuroendocrine tumor (carcinoid tumor) and its potential diagnostic pitfalls.     

Metastatic Breast Cancer Survival according to HER2 and Topo2a Gene Status

The aim of this study was to determine the relationship between amplification of HER2 (Human epidermal growth factor receptor 2) and Topo2a (topoisomerase 2a) and their influence on prognosis in metastatic breast cancer (MBC) patients. Amplification of both HER2 and Topo2a genes was determined by chromogenic in situ hybridization (CISH) in primary tumor tissue of 71 MBC patients. Starting point for follow-up was the time of diagnosis of metastatic disease. Although there was significant correlation between HER2 amplification and Topo2a alterations, Topo2a amplification was not strictly related to HER2 amplification. Follow-up of patients showed that there was no difference in MBC survival between HER2-nonamplified and HER2-amplified patients for subgroup as whole, but there was significant difference in MBC survival between patients with and without Topo2a amplification. HER2 amplification showed prognostic value in subgroups of patients, as well as Topo2a. Combination of these two genes with different status (nonamplified, amplified, coamplified) indicated that they might have additive effect. Also, it has been shown that Topo2a-amplified cases have poorer survival than Topo2a-nonamplified, when treated with CMF therapy.Topo2a amplification seems to be more promising biomarker of MBC survival, than HER2, and potential marker of resistance to CMF therapy.     

HER2高表达的人乳腺癌原代细胞模型的建立

目的:探讨人乳腺癌恶性胸水肿瘤细胞的分离、纯化、培养与肿瘤细胞的鉴定,为HER2阳性的人乳腺癌的研究提供肿瘤原代细胞模型.方法:利用淋巴细胞分离液及密度梯度离心法分离、纯化恶性胸水肿瘤细胞,分离得到的细胞培养并传至第5代,通过流式细胞仪分选肿瘤细胞、Q-PCR技术、Western blot技术验证细胞HER2分子的表达水平、通过裸鼠荷瘤实验检测细胞的成瘤能力.结果:淋巴细胞分离液及密度梯度离心法分离得到乳腺癌原代细胞;流式细胞分选结果显示未分选出HER2高表达的肿瘤细胞;Q-PCR及Western blot检测发现分离得到的细胞在mRNA及蛋白水平HER2的表达水平高于乳腺癌MCF-7细胞;裸鼠荷瘤实验结果显示分离得到的细胞可以成功荷瘤.结论:胸水中分离得到的细胞为HER2阳性的乳腺癌原代细胞;对于原代细胞的鉴定需要采用不同的方法加以论证.     

Malignant cell detection by fluorescence in situ hybridization (FISH) in effusions from patients with carcinoma

Cytological diagnosis of malignant cells in effusions is hampered by difficulties in the differentiation from reactive mesothelial cells. Because interphase cytogenetics by fluorescence in situ hybridization (FISH) might complement cytological evaluation, we determined the power of tumor cell detection using FISH and cytology in 201 effusions from patients with advanced cancer. Furthermore, 9 primary breast tumors were FISH-karyotyped, and chromosomal aberrations were compared with those of corresponding metastatic effusion cells. By using centromeric probes representing chromosomes 7, 8, 11, 12, 17, and 18, a rate of malignancy-associated aneusomy combined for the 6 chromosomes was detected in an overall of 44.8% of effusion specimens (range, 31.8% to 39.3% for the individual chromosome), comparable to cytology (43.3%). The combination of just 2 FISH probes (namely, representing chromosome pairs 8/11 and 8/17) was almost equally efficient in the identification of aneusomy. Approximately one fourth of the cytologically negative effusions were FISH positive and vice versa. From the initially FISH-negative effusions, 18.9% could be subsequently classified positive with dual-color FISH by visualization of intranuclear chromosomal complexity in rare aneuploid cells. Thus, "overall FISH analysis," including dual-color evaluation, identified tumor cells in significantly more effusions (55.2%, P = .001) than conventional cytology, implying greater sensitivity. Finally, our finding that numerical aberration patterns in primary breast tumors and corresponding metastatic effusions are comparable indicates that FISH examination of primary tumors will indicate the centromeric probe(s) best suited for an efficient search for metastasis in the individual case.     

Cytological diagnosis of metastatic glioblastoma in the pleural effusion of a lung transplant patient

The extracranial metastasis of glioblastoma is a rare event. We report the case of a patient who developed metastatic glioblastoma in pleural effusion 15 months after lung transplant, with emphasis on differential diagnosis based on cytological material. In our case, tumor cells had pleomorphic nuclei, prominent nucleoli, and fine vesicular chromatin. Some were arranged in a poorly formed pseudo‐glandular architecture, mimicking a poorly differentiated adenocarcinoma. The cytological diagnosis of metastatic glioblastoma is difficult and depends critically on clinical history and suspicion, particularly in the transplant setting. Review of the literature indicates that transmission/metastasis of intracranial malignancy occurs rarely following organ transplantation, with some debate on the suitability for transplant of organs from affected donors. Although the situation is uncommon, this report of the cytological findings of extracranial glioblastoma may extend our current knowledge and provide additional differential diagnostic information for this entity. Diagn. Cytopathol. 2014;42:619–623. © 2013 Wiley Periodicals, Inc.     

Carcinoid of the Ovary

Carcinoid of the ovary is an uncommon tumor. In the present article we have described the cytological features of carcinoid of the ovary in a 53‐year old post‐menopausal female. The patient presented with abdominal discomfort and loose stools. Ultrasound‐guided fine‐needle aspiration cytology (FNAC) of the left adnexal mass showed clusters and also scattered, relatively monomorphic population of tumor cells with vague rosette‐like structures. Cytological diagnosis of malignant ovarian tumor possibly sex cord stromal tumor or carcinoid of ovary was offered and subsequent histopathology and immunohistochemistry confirmed the diagnosis of carcinoid. Diagn. Cytopathol. 2014;42:612–614. © 2013 Wiley Periodicals, Inc.     

Metastatic metaplastic carcinoma of the breast: diagnosis by bronchial brush cytology

Metaplastic carcinoma of the female breast is an uncommon lesion that may metastasize to body sites. To our knowledge, this is the first reported case of pulmonary metastasis diagnosed on bronchial brush cytology. The patient presented with pulmonary symptomatology 1 yr and 3 mo after a left modified radical mastectomy for breast carcinoma. Bronchoscopic examination revealed an endobronchial lesion partially obstructing the bronchus intermedius. Bronchial brush cytology showed the presence of nonkeratinizing squamous tumor cells admixed with a few scattered clusters of tumor cells with glandular features. Histologic review of the original breast lesion showed a metaplastic carcinoma of the breast with a predominant squamous-cell component. Accurate knowledge of a patient's clinical history is necessary to differentiate a second primary lesion from a metastatic one, particularly when the original lesion is so uncommon.     

Gastric carcinoma with an invasive micropapillary carcinoma component showing HER2 gene amplification and CD10 expression: A case report and review of the literature

An 81‐year‐old man was referred to our hospital because gastric cancer was detected on screening esophagogastroduodenoscopy. Surgical resection of the tumor was performed. It was 25 × 20 mm in size and swollen lymph nodes were present nearby. Lymphadenectomy was also performed. Histopathologically, the tumor reached the proper muscle layer via venous invasion. There were three components that constituted the tumor, that is, 40% of mass was invasive micropapillary carcinoma (IMPC), 40% was papillary adenocarcinoma and 20% tubular adenocarcinoma. Vascular invasion was prominent. Immunohistochemistry revealed that the tumor showed an entirely intestinal mucin phenotype, being positive only for CD10 and negative for MUC2, MUC5AC, and MUC6. HER2 staining score ranged from 2+ to 3+, depending on the components described above. HER2 gene amplification was present in all the components according to dual‐color in situ hybridization. The metastatic lymph nodes were similar to the primary site in morphology and immunohistochemistry, but HER2 amplification was higher in the lymph nodes. The IMPC component with HER2 amplification is rarely seen and its positivity for CD10 is an unexpected finding for gastric IMPC. Hence, this is a highly unusual case judging by the literature; further studies are needed to clarify the nature of gastric IMPC.     

Cytological findings of mixed squamous cell and glandular papilloma in the lung

Pulmonary mixed squamous cell and glandular papilloma is an extremely rare neoplasm. This is the first cytological report of such a rare neoplasm. A 59‐year‐old Japanese man was admitted to the hospital complaining of a persistent cough and bloody sputum. A bronchial endoscopic examination revealed an endobronchial polypoid tumor. Upon bronchial brush cytology by Papanicolaou stain, squamous dysplasia showing mild atypia was suspected. The smears showed moderate cellularity with singly scattered cells or loose clusters of cells, consisting of squamous cells and a few columnar cells. Nuclei of the squamous cells showed mild atypia, but there was no nuclear atypia of the columnar cells. Upon intraoperative pathological examination by frozen section, pulmonary mixed squamous cell and glandular papilloma was suspected. Intraoperative imprint cytology by Ultrafast Papanicolaou stain showed a few differences in comparison with bronchial brush cytology, which were thought to be due to differences in obtaining cytological specimens or the steps prior to the staining. The patient underwent a segmentectomy of the left lung. Histopathological diagnosis confirmed a mixed squamous cell and glandular papilloma. The postoperative course has been uneventful for 5 years after surgery. It was thought that cytology was diagnostically inadequate on its own in the present case. However, mixed squamous cell and glandular papilloma must be considered as another type of pulmonary tumor in cytological preparations, especially in a case showing endobronchial papillary growth by bronchoscopy. Diagn. Cytopathol. 2010;38:913–917. © 2010 Wiley‐Liss, Inc.