Pancreatic fine‐needle aspiration cytology in patients < 35‐years of age: A retrospective review of 174 cases spanning a 17‐year period

Pancreatic lesions in young patients are relatively rare and, to our knowledge, the clinical value of pancreatic fine needle aspiration (FNA) in patients < 35 years of age has not been previously established by any other large retrospective studies. All pancreatic endoscopic ultrasound‐guided FNA (EUS‐FNA) cases performed on patients < 35 years of age were identified for a 17‐year period (1994–2010). All FNAs and all available correlating surgical pathology reports were reviewed. There were a total of 174 cases of pancreatic FNA performed on 109 females and 65 males under the age of 35 (range: 8–34, mean: 27 years). The FNA diagnoses included 37 malignant, 114 negative, nine atypia/suspicious, and 14 cases that were nondiagnostic. Of the 37 malignant FNA cases, the diagnoses included 18 pancreatic neuroendocrine tumors (PanNeT), 11 solid pseudopapillary neoplasms (SPN), five adenocarcinomas and three metastatic neoplasms. Histologic follow‐up was available in 22 of the 37 malignant cases diagnosed by FNA, and the diagnosis was confirmed in 21 cases. One pancreatoblastoma was misclassified as SPN on EUS‐FNA. False negative diagnoses were noted in three cases of low‐grade mucinous cystic neoplasm and one case of PanNeT. The most common type of neoplasms diagnosed by EUS‐FNA in patients < 35‐year old is PanNeT, followed by SPN with both tumors accounting for 75% of all the neoplasms encountered in this age group. The sensitivity and specificity for positive cytology in EUS‐FNA of the pancreas to identify malignancy and mucinous neoplasms were 90% and 100%, respectively. Diagn. Cytopathol. 2014;42:297–301. © 2013 Wiley Periodicals, Inc.     

The oncocyte that went places: Diagnosis with EUS‐guided FNA

Although uncommon, Hurthle cell neoplasms have a characteristic histologic and cytologic features which often aid in the diagnosis of these lesions. In fine needle aspiration biopsies, determining malignant potential on cytologic features is challenging unless other evidence of malignancy (such as metastases) are known. The role of EUS‐guided FNA in diagnosing superior mediastinal masses has been described previously. It's role in evaluating subcarinal metastases from lung cancer primaries have also heen studied. However we describe metastatic thyroid Hurthle cell carcinoma to the subcarina diagnosed through EUS‐guided FNA combining the unique cytologic features o Hurthle cell neoplasms and the versatility ofthe endoscopic ultrasound to reach a diagnosis in this unusual neoplasm. Diagn. Cytopathol. 2013;41:977–979. © 2011 Wiley Periodicals, Inc.     

Diagnosis of metastatic pancreatic mesenchymal tumors by endoscopic ultrasound‐guided fine‐needle aspiration

Involvement of the pancreas by metastatic sarcoma is rare, and can prove challenging to differentiate from sarcomatoid carcinomas which occur more commonly. The endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) technique has been successfully used for the diagnosis of pancreatic carcinomas whether primary or metastatic, and is now considered the most effective noninvasive method for the identification of pancreatic metastases. However, to date very few reports detail the diagnosis of mesenchymal neoplasms by EUS‐FNA. Herein, we report a series of four patients who underwent EUS‐FNA of the pancreas, where the diagnosis of metastatic sarcoma was made based on morphology and ancillary studies. The cases include metastases of leiomyosarcoma, liposarcoma, alveolar rhabdomyosarcoma, and solitary fibrous tumor. The history of a primary sarcoma of the chest wall, mediastinum, and respectively lower extremity was known for the first three of these patients while in the case of the solitary fibrous tumor a remote history of a paraspinal “hemangiopericytoma” was only elicited after the EUS‐FNA diagnosis was made. We conclude that EUS‐FNA is efficient and accurate in providing a diagnosis of sarcoma, even in patients without a known primary sarcoma, thus allowing institution of therapy without additional biopsies. Diagn. Cytopathol. 2009. © 2009 Wiley‐Liss, Inc.     

Secondary tumors of the pancreas diagnosed by endoscopic ultrasound‐guided fine‐needle aspiration: A 10‐year experience

Determining whether a pancreatic mass is a primary or secondary neoplasm is necessary for appropriate treatment. We reviewed our experience using endoscopic ultrasound‐guided fine needle aspiration (EUS‐FNA) for diagnosis of pancreatic tumors to identify clinical and cytopathologic characteristics of metastatic disease. We reviewed all cases of tumors metastatic to the pancreas evaluated at The University of Texas MD Anderson Cancer Center and The Methodist Hospital in Houston, Texas during the period from 2002 to 2012. The review included cytologic specimens, clinical history, radiologic findings, primary tumor type, and clinical follow‐up. We identified 66 patients with disease metastatic to the pancreas for which cytologic material was available: 38 (58%) men and 28 (42%) women, with an average age of 63 years (range, 40–89 years). Most metastases (98%) were single lesions, and nearly half were located in the head of the pancreas (30/66). The most common site of origin for these metastases was kidney (27 [41%] cases). Follow‐up information was available for 65 (98%) patients, and duration of follow‐up ranged from <1 to 10 years (mean, 2.3 years). Thirty‐three patients (50%) were alive at the time of the most recent follow‐up contact. Of the 25 patients with metastatic renal cell carcinoma, clear cell type, 19 (76%) were alive at the time of the most recent follow‐up. It was concluded that metastases may mimic primary pancreatic carcinomas both clinically and cytologically. Ancillary studies in conjunction with clinical history are necessary for the accurate diagnosis of FNAs of secondary pancreatic tumors. Diagn. Cytopathol. 2014;42:738–743. © 2014 Wiley Periodicals, Inc.     

Sampling of the adrenal glands by endoscopic ultrasound-guided fine-needle aspiration

Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) has proven to be a valuable modality for the primary diagnosis and staging of gastrointestinal, and perigastrointestinal malignancy. Aside from assessing thoracic and abdominal lymph nodes and the liver for metastases, EUS can assess and sample the adrenal glands, which are frequently involved by metastatic disease, but can also harbor benign primary neoplasms. The cytology files at our institution were reviewed for all cases of EUS-guided FNA of the adrenal glands. Clinical histories, sonographic findings, and cytologic findings of all cases were reviewed. Results were compared with overall EUS-guided FNA performance and the performance of non-EUS-guided FNA of the adrenal. The utility of cell block immunohistochemistry (IHC) in these cases was reviewed. Between 1/1/00 and 5/15/04 there were 24 cases of EUS-guided FNA of the adrenal gland from 22 different patients (13 men; 9 women) at our institution. This represented 1.4% of overall EUS-guided FNA and 77% of adrenal gland FNA. Patient ages ranged from 37 to 86 yr (mean 69 +/- 11 yr). Most patients had other cancers or mass lesions and were being staged at the time of the procedure (19 of 22). Almost all FNAs were of the left adrenal gland (23 of 24). Lesion size ranged from 0.9 to 7.9 cm (mean 2.5 +/- 1.6 cm). Diagnostic material was present in all cases when compared with an overall EUS-guided FNA diagnostic rate of 88%. Material for cell block was present in 21 cases, and IHC was used in 3 cases. Final diagnoses were as follows: cortical tissue consistent with cortical adenoma (19), metastatic adenocarcinoma (3), pheochromocytoma (1), and adrenal cortical carcinoma (1). EUS-guided FNA of the adrenal gland is primarily used in the staging of other malignancies when lesions of the left adrenal are recognized sonographically. Diagnostic tissue is easily obtained, including material for cell block IHC, which allows definitive diagnosis in cases that present difficult differential diagnoses.     

Endoscopic ultrasonography‐guided fine‐needle aspiration for diagnosing upper gastrointestinal submucosal lesions: A prospective study of 50 cases

The objective was to assess EUS‐FNA for diagnosing intramural upper GI tract lesions. The subjects were 50 patients (21M/29F) with upper GI submucosal lesions who underwent EUS‐FNA at a referral center for GI system over a 12‐month period. All cases were followed for 1 year after initial EUS‐FNA. Cytologic diagnoses were categorized as benign, malignant, suspicious for malignancy, mesenchymal tumor, endocrine tumor, or nondiagnostic. All tumors were assessed for various cytomorphologic features. The accuracy of the initial FNA diagnoses was evaluated for each patient who also underwent subsequent histopathological examination of a core biopsy and/or surgical biopsy/resection material of the same lesion. According to the site of the lesions; while 84% of all esophageal lesions were diagnosed as mesenchymal; 67% of all gastric lesions were mesenchymal. The sole lesion was nonmesenchymal (benign cyst) in duodenum. The sensitivity, specificity, positive and negative predictive values, and accuracy of EUS‐FNA for diagnosing submucosal mesenchymal tumors of the upper GI tract were 82.9, 73.3, 87.9, 64.7, and 80%, respectively. The corresponding values for nonmesenchymal lesions were 100, 85.7, 80, 100, and 90.9%. Our experience confirms that EUS‐FNA is an extremely valuable tool for diagnosing submucosal lesions of the upper GI, and is particularly useful in cases where endoscopic forceps biopsy does not lead to diagnosis. Optimal results can be yielded by a close working relationship between the gastroenterologist and pathologist. Diagn. Cytopathol. 2011. © 2010 Wiley‐Liss, Inc.     

Fluorescence in situ hybridization as an adjunct tool in the diagnosis of primary and metastatic renal cell carcinoma in fine needle aspiration specimens

We investigated the role of fluorescence in situ hybridization (FISH) in the diagnosis of primary renal neoplasms and lesions suspicious for metastatic renal cell carcinoma. Consecutive fine‐needle aspiration biopsies (FNAB) of 39 renal masses and 41 metastatic tumours suspicious for renal cell origin were assessed with an immunohistochemical panel for CK7, RCC antigen, CD10, AMACR, PAX8, vimentin, and CD117. In addition, FISH was performed using probes for chromosomes 1p, 3p, 7, 17, X, and Y. A total of 31 of 39 primary renal masses and 33 of 41 metastatic tumors suspicious for renal origin demonstrated typical cytological and immunohistochemical (IHC) features of subtypes of renal neoplasms (40 clear cell renal cell carcinoma (RCC), 20 papillary RCC, and 4 renal oncocytomas). FISH analysis of 15 randomly selected cases each of primary and metastatic lesions revealed chromosomal abnormalities consistent with the diagnosis in 73% of these cases. Of 8 primary renal masses demonstrating atypical microscopic features and noncontributory IHC profiles, FISH was helpful in subtyping 5 (62%) of these lesions (2 clear cell RCC, 1 solid variant of oncocytic papillary RCC, 1 mixed clear cell and papillary RCC, and 1 chromophobe RCC with papillary architecture). Of 8 metastatic tumors clinically suspicious for renal cell origin and supportive, but nondiagnostic IHC, FISH revealed supportive chromosomal changes in 6 (75%) cases. In conclusion FISH analysis on FNAB material, even with limited tissue, may be contributory to the diagnosis and subtyping of RCC in diagnostically challenging biopsies. Diagn. Cytopathol. 2014;42:1013–1023. © 2014 Wiley Periodicals, Inc.     

Pancreatic masses: A multi-institutional study of 364 fine-needle aspiration biopsies with histopathologic correlation

Only 15% of primary malignant tumors are confined to the gland at the time of presentation. Fine-needle aspiration (FNA) is valuable in confirming the malignant nature of these unresectable lesions. Benign pancreatic lesions and metastatic neoplasms can also be evaluated by fine-needle aspiration. We undertook a retrospective study to evaluate the efficacy of FNA in assessing pancreatic masses. Three hundred and sixty-four radiologically guided FNAs of the pancreas performed between 1986–1996 were reviewed. Surgical material was also evaluated when available and compared to the FNA material. There were 223 men and 141 women. Their ages ranged from 23–90, with a mean of 64 yr. Two hundred and twelve patients (58%) had primary malignant tumors, 183 had adenocarcinomas, 15 had mucinous cystadenocarcinomas, 12 had neuroendocrine tumors, and 2 had pleomorphic giant-cell carcinomas. Ninety-one (43%) had available surgical material which showed adenocarcinoma. Ninety-one patients (25%) had benign aspirates, including 53 showing benign ductal epithelium, 23 showing pancreatitis/inflammation, 10 showing pseudocysts, and 7 showing serous cystadenomas. Surgical material was available in 24 (26%) of these patients. Two of these showed adenocarcinoma. Sixteen aspirates (4%) were suspicious for malignancy, 13 (81%) of which showed adenocarcinoma on follow-up biopsies. Twenty-two aspirates (6%) showed metastatic neoplasms. Twenty-three (6%) had unsatisfactory specimens. Ten (43%) of these had follow-up biopsies, 3 of which were malignant. FNA of primary benign and malignant pancreatic masses is highly sensitive (98%) and specific (100%). Eighty-one percent of the suspicious lesions showed adenocarcinoma on follow-up biopsy. FNA of metastatic neoplasms to the pancreas is also very accurate. This technique can be useful in avoiding unnecessary surgery. Diagn. Cytopathol. 1998;19:423–427. © 1998 Wiley-Liss, Inc.     

EUS‐guided 22‐gauge fine‐needle aspiration versus core biopsy needle in the evaluation of solid pancreatic neoplasms

Endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) is widely used for diagnosis of pancreatic lesions. The Echotip Procore Needle (Wilson‐Cook Medical) is a new 22G fine biopsy needle (FNB) for obtaining core biopsy material at time of EUS. This study aimed to compare the technical and diagnostic performance of conventional FNA and FNB. Thirty‐two patients met the design criteria for this prospective paired cohort study. All lesions sampled were solid (non‐cystic) pancreatic masses by EUS appearance. Patients were randomized to receive FNA or FNB by first attempt. A cytopathologist performed on‐site evaluations. Samples were assessed for accuracy of diagnosis, cellularity, contamination, and sufficiency for ancillary studies. Technical and diagnostic performances were compared. Compared to FNA, there was a statistically significant decreased ability of FNB to achieve a diagnosis (FNA 93.8%, FNB 28.1%, P < 0.001). FNB was diagnostically superior to FNA in 1 of 32 cases. Technical failures were observed in five cases due to resistance to advancement of the FNB needle. Regarding operator perceived ease‐of‐use, FNA outperformed FNB (P < 0.001). Eight cases had insufficient FNB material to survive tissue processing. There was no significant difference in mean specimen cellularity between devices. FNA samples showed an increased amount of contaminant (P = 0.036) but were more sufficient for ancillary studies (P = 0.502). Although deemed comparable to FNA when providing material for cytology, the pledged advantage of FNB acting like a core biopsy needle was not apparent in our series. Additional studies are needed before routine adoption of 22G FNB can be recommended. Diagn. Cytopathol. 2014;42:751–758. © 2014 Wiley Periodicals, Inc.     

Utilization of fine-needle aspiration in the diagnosis of metastatic tumors to the kidney.

Renal masses secondary to metastases are not common. Few comprehensive reviews exist, which consist primarily of autopsy and radiologic reports. The purpose of this study was to review the types and incidences of various neoplasms which metastasize to the kidney and to determine the usefulness of fine-needle aspiration (FNA) in diagnosing them. Two hundred and sixty-one radiologically guided FNAs of renal lesions over a 9-yr period were reviewed. The diagnoses of the 261 renal FNAs were as follows: 136 (52%) were malignant, 111 (43%) were benign, and 14 (5%) were unsatisfactory. Of the 136 positive FNAs, 28 (21%) revealed metastatic tumors. The overall incidence of renal FNAs displaying metastatic tumors was 11%. Among the 28 patients with metastases to the kidney, 23 patients were men and 5 were women, with the mean age being 58 yr. Twenty-five patients (89%) had prior history of a primary malignancy, including lung carcinoma (11 cases, 39%), lymphoma (8 cases, 29%), hepatocellular carcinoma (3 cases, 11%), and one case each of breast, pancreatic, and cervical cancer. In the remaining 3 patients (11%), with metastatic adenocarcinoma (2 cases) and squamous-cell carcinoma (1 case), the primary tumor site remained unknown despite an extensive clinical workup. Overall survival after FNA was poor, with a mean of 9.8 mo. FNA is useful in the diagnosis of masses in the kidney secondary to metastatic disease. This information is of clinical importance, principally in the exclusion of a primary malignancy, but also to avoid unnecessary surgery and to plan for subsequent patient care.     

A case of metastatic rectal adenocarcinoma diagnosed by thyroid cytology

Fine‐needle aspiration (FNA) cytology of the thyroid gland has been widely used for the evaluation of thyroid nodules. Most of the nodules are primary thyroid lesions. However, up to 4% of thyroid FNA may harbor a metastatic neoplasm. The metastases are most commonly from lung, kidney, breast, and skin. Metastatic colorectal cancers are also seen in thyroid but less common. Here we report the cytologic features, differential diagnosis and clinical implications of a metastatic rectal adenocarcinoma to the thyroid gland diagnosed by FNA.     

Percutaneous image-guided fine-needle aspiration of peritoneal lesions

Fine-needle aspiration (FNA) is a widely accepted technique for the initial tissue diagnosis of a variety of lesions arising within retroperitoneal and intraabdominal viscera. Fear of complications secondary to perforation of the bowel wall has limited the use of FNA in the diagnosis of gastrointestinal and peritoneal masses. A variety of primary and secondary neoplasms involving the peritoneum may present as multiple nodules, as masses, or as diffuse involvement of the peritoneum. When these lesions are associated with mass lesions or areas of significant peritoneal thickening, they become amenable to percutaneous image-guided FNA. We report on our experience with a series of 23 peritoneal lesions investigated by FNA for which subsequent histologic confirmation was available in 19, along with an additional 4 cases without histologic confirmation. One to four passes were made into each lesion, and immediate assessment for adequacy was performed by a cytopathologist in all cases. All 17 cases with a specific cytologic diagnosis and histologic confirmation represented either primary or metastatic neoplasms (5 gastrointestinal stromal tumors, 4 metastatic melanomas, 2 mesotheliomas, 1 lymphoma, 1 example of Kaposi's sarcoma, 1 serous papillary carcinoma of ovarian origin, 1 mucinous adenocarcinoma of ovarian origin, 1 intraabdominal desmoplastic small-cell tumor, and 1 solitary fibrous tumor of the peritoneum). In an additional 4 cases, the aspirates were judged as insufficient for diagnosis, with the smears containing only blood and benign mesothelial cells and/or inflammatory cell elements. These four smears were associated with both neoplastic and nonneoplastic lesions. Surgical confirmation was obtained in only 2 of these cases (1 metastatic melanoma and 1 example of omental and peritoneal involvement by an ovarian adenocarcinoma). Two cases without histologic confirmation were associated with clinically confirmed metastases. In our series, no acute or chronic postprocedural complications were identified, indicating that FNA in this setting is a safe technique. Accurate cytologic diagnosis was achieved in 74% of cases. The overall insufficiency rate was 26%.     

Significance of the diagnostic categories “atypical” and “suspicious for malignancy” in the cytologic diagnosis of solid pancreatic masses

Endoscopic ultrasound guided (EUS) fine‐needle aspiration (FNA) investigation of solid pancreatic lesions has been shown to have good sensitivity and specificity. Many lesions can be definitely classified as benign or malignant but some can only be cytologically classified as “atypical” or “suspicious for malignancy”. Risk for malignancy in these indeterminate categories has not been well categorized. The cytology records of four University Medical centers were searched for all EUS guided FNAs of solid pancreatic lesions. All cases with a diagnosis of “atypical”, or “suspicious for malignancy” were selected for analysis when histologic biopsy or over 18 months clinical follow‐up was available. Two hundred and ninety‐two cases with a diagnosis of “atypical” or “suspicious for malignancy” and adequate follow‐up were obtained from the combined data of the four institutions. The percentage malignant for the categories “atypical” and “suspicious for malignancy” were 79.2 and 96.3%, respectively. If the category “atypical” was classified as benign and “suspicious for malignancy” was classified as malignant, the resulting positive predictive value was 96.3 (95% CI: 92.6–98.5) and the negative predictive value 20.8 (95% CI: 13.4–30.0). The categories of “atypical” and “suspicious for malignancy” stratify risk for malignancy in a fashion, which may aid in patient counseling and selection of follow‐up protocols. Classification of “suspicious for malignancy” as malignant optimizes diagnostic sensitivity and specificity. Diagn. Cytopathol. 2014;42:292–296. © 2014 Wiley Periodicals, Inc.     

Endoscopic ultrasound‐guided fine‐needle aspiration diagnosis of merkel cell carcinoma metastatic to the pancreas

Merkel cell carcinoma (MCC) is a rare and highly aggressive primary neuroendocrine carcinoma of the skin with a high propensity for local, regional, and distant spread. Distant metastasis of MCC to the pancreas is uncommonly seen and may impose a diagnostic challenge cytologically. Here we report a case of MCC with pancreatic metastasis, which was diagnosed by endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA). The aspirates revealed both single and clustered epithelial cells with scant cytoplasm and round nuclei with stippled chromatin and inconspicuous nucleoli. Immunocytochemically, the tumor cells were positive for CK20, synaptophysin, CD56, and CD117. The neoplastic cells were also identified by flow cytometry as non‐hematopoietic cells which were positive for CD56 and negative for CD45. To our knowledge, this is only the second case report of MCC metastatic to the pancreas diagnosed by EUS‐FNA. There have been several reports of MCC metastatic to the pancreas diagnosed only at the time of surgical resection. However, a preoperative diagnosis allows for appropriate management while sparing a patient the morbidity of unnecessary procedures. Diagn. Cytopathol. 2014;247–252. © 2012 Wiley Periodicals, Inc.     

The usefulness of S100P,mesothelin, fascin,prostate stem cell antigen,and 14‐3‐3 sigma in diagnosing pancreatic adenocarcinoma in cytological specimens obtained by endoscopic ultrasound guided fine‐needle aspiration

Endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) of the pancreas is an efficient and minimally invasive procedure for the diagnosis and staging of pancreatic adenocarcinoma. Because of some limitations of EUS‐FNA in diagnosis of well‐differentiated or early stage cancers, the purpose of this study is to assess the added benefit of immunohistochemistry. We studied five proteins overexpressed in pancreatic adenocarcinoma, namely, prostate stem cell antigen, fascin, 14‐3‐3 sigma, mesothelin and S100P utilizing immunohistochemistry on paraffin sections from cellblocks obtained by EUS‐FNA. Sixty‐two cases of EUS‐FNA of the pancreas that had follow‐up histological and/or clinical diagnosis and sufficient material in cell blocks were included. Using histological diagnosis and/or clinical outcome as the reference standard, EUS‐FNA shows the highest sensitivity (95%) and specificity (91%) and is superior to any marker in this study. Among five antibodies, S100P reveals the best diagnostic characters showing 90% of sensitivity and 67% of specificity. Fascin shows high specificity (92%) but low sensitivity (38%). Mesothelin has a moderate sensitivity (74%) and low specificity (33%), PSCA and 14‐3‐3 show high sensitivity but zero specificity. S100P and mesothelin were useful in nine indeterminate cases. S100P correctly predicted six of seven cancers and one of one without cancer and mesothelin correctly diagnosed five of seven cancers and one of two noncancers in this group. EUS‐FNA cytomorphology is superior to any of the immunohistochemical markers used in this study. Use of S100P and mesothelin in cytologically borderline cases can increase the diagnostic accuracy in this group. Diagn. Cytopathol. 2014;42:193–199. © 2011 Wiley Periodicals, Inc.     

Fine‐needle aspiration findings of a rare hematopoietic neoplasm presenting as obstructive jaundice

A 51‐year‐old female who presented with obstructive jaundice was found to have masses in the pancreatic head and tail as well as suspicious liver and periaortic masses on imaging. Aspiration cytology of the pancreatic tail mass showed abundant large single cells with vacuolated eosinophilic cytoplasm, marked nuclear pleomorphism, large bizarre irregular nuclei, binucleation, and prominent nucleoli. Numerous cells also showed intracytoplasmic black to brown pigmentation. A cell block was obtained and extensive immunohistochemical staining was performed. S‐100, HMB‐45, Sox10, pancytokeratin, CK7, RCC antigen, synaptophysin, HepPar 1, inhibin, CD45, CD21, and CD123 were negative, making melanoma, epithelial malignancies, lymphoma, follicular dendritic and plasmacytoid dendritic cell neoplasms less likely. CD4 and CD56 showed partial positivity, and CD68, CD163, and CD14 were positive, supporting the diagnosis of histiocytic sarcoma. Surgical specimens and immunohistochemistry confirmed the cytologic findings. Histiocytic sarcoma is a rare aggressive malignancy of histiocytic origin with most cases presenting in adults in extranodal sites, most commonly the intestinal tract. Few cases are reported in the literature, presenting diagnostic challenges for cytopathologists when seen on fine‐needle aspiration. We present the first reported case of histiocytic sarcoma presenting as a pancreatic mass, diagnosed by endoscopic ultrasound guided fine‐needle aspiration (EUS‐FNA). This entity is rarely described on cytology and arose in a location in which EUS‐FNA is the diagnostic modality of choice. This case study highlights that cytopathologists should be aware of histiocytic sarcoma occurring in extranodal locations accessible by EUS‐FNA and be familiar with the cytomorphologic appearance.     

Liver lesions in children and adolescents: cytopathologic analysis and clinical correlates in 44 cases

The role of fine needle aspiration (FNA) as a first-line diagnostic modality is well-established for neoplastic and nonneoplastic liver masses in adults. However, cytopathologic analysis of such lesions in children and adolescents has not been well studied. An 18-year retrospective review of the cytopathology archives at The Johns Hopkins Hospital identified 44 cases of hepatic FNA in children and adolescents (i.e., 21 years and younger). The cytopathologic material was reviewed and correlated with subsequent surgical pathology diagnoses and/or clinical follow-up. Among the 44 FNAs studied, 40 (90.9%) were deemed diagnostic for evaluation and 4 (9.1%) were nondiagnostic. Twenty four (60%) of the diagnostic FNAs were neoplasms, 10 (25%) were nonneoplastic lesions, and 6 (15%) were "atypical" or "suspicious." There were 21 (87.5%) malignant and 3 (12.5%) benign tumors. Among the malignant cases, metastases/secondary tumors accounted for 12 (54.5%) followed by hepatocellular carcinoma (HCC)--7 (38.1%). The types of metastatic/secondary neoplasms were Wilms tumor (2), germ cell tumor (2), acute leukemias (2), and miscellaneous others (6). Among the nonneoplastic lesions focal nodular hyperplasia was most common--4 (40%). Among the "atypical" cases, 4 (66.6%) turned out to be benign on follow-up, 2 were HCC, and 1 was Hodgkin lymphoma. Immunoperoxidase (IPOX) studies were done in 20 (45.5%) cases to confirm the cytopathologic diagnoses. Overall, FNA showed a sensitivity of 95.2% and a specificity of 100% for a malignant diagnosis.     

Sacral and presacral lesions: cytopathologic analysis and clinical correlates

Although percutaneous biopsies of the spine at thoracolumbar levels have proven value, the benefit in the sacrococcygeal region has not been presented thoroughly in the literature. This region has unique anatomic and oncologic properties. The cytopathologic files at The Johns Hopkins Hospital over a 20-year-period were searched. Imaging studies and medical records were also reviewed. Ninety-one cases of sacral/presacral FNA were identified. There were 46 males and 45 females; 62% had a prior history of malignancy. The most common presentation was lower back pain (44%). Imaging revealed lytic and/or soft tissue lesions masses from 1 to 12 cm (mean = 5.0 cm). Of the 71 (78%) diagnostic cases, 19 (27%) were nonneoplastic, 2 (3%) were suspicious for neoplasm, while 50 (70%) cases were neoplastic. Of the nonneoplastic cases, 10 (53%) showed nonspecific inflammation. Two (4%) of the 50 neoplastic lesions were benign tumors (schwannoma and neurofibroma), and of the malignant cases, 11 (23%) were primary, and 37 (77%) were metastatic/secondary. The most common primary malignant tumor was chordoma (four cases, 36%). Of the 37 secondary tumors, the most common were colorectal carcinoma (8, 22%) and plasmacytic tumors (5/9, 56%). The overall accuracy, sensitivity and specificity of FNA were 96, 95, and 100%, respectively. Sacral and presacral lesions represent rare targets for FNA. Benign tumors are rare (2%). Most cancers are metastatic (41%), with colorectum being the most common primary site (9%). Primary malignancies are uncommon (14%), with chordomas being the most frequent of these entities (4%).     

Giant cell tumor of bone presenting in the lumbar spine of a 35‐Year‐old Female

Fine‐needle aspiration (FNA) is commonly used in the evaluation of both primary and metastatic bone lesions. Giant cell tumor (GCT) of bone is one of the primary bone neoplasms that can be diagnosed with good success on FNA as its cytologic features are relatively reproducible. However, this entity classically involves the ends (or epiphyses) of the longs bones making an FNA diagnosis of a GCT of bone in other anatomic locations is challenging and requires the consideration of a differential diagnosis. By invoking clinico‐radiographical correlation and maximizing our specimen, we were able to diagnose a GCT of bone involving the L1 vertebral body in a 35‐year‐old female. Diagn. Cytopathol. 2014;42:624–627. © 2013 Wiley Periodicals, Inc.     

Endoscopic ultrasound‐guided fine needle aspiration (EUS‐FNA) of mediastinal lymph nodes: Experience from region with high prevalence of tuberculosis

Utility of EUS‐FNA in diagnosing granulomatous lesions of mediastinum in regions with high prevalence of tuberculosis has not yet been evaluated. In the present study, utility and limitations of EUS‐FNA of mediastinal lesions from a tertiary care center with high prevalence of tuberculosis were studied. All cases where EUS‐FNA had been performed to diagnose mediastinal lymphadenopathy from January 2006 to December 2008 were retrieved from the files of cytopathology laboratory. These were reviewed by the cytopathologist. Two hundred and eighty one EUS‐FNA aspirates from 269 patients were evaluated. Satisfactory aspirates were available in 259 cases. A cytological diagnosis of granulomatous lymphadenitis was rendered in 206 cases. Of these, tuberculosis could be established as an etiology in 76 cases and sarcoidosis in 7 cases only. In remaining 123 cases the etiology of granulomatous lymphadenitis could not be established and clinical correlation was suggested. Malignancies were diagnosed or suspected in 24 and 5 cases, respectively. The study highlights that the dilemma of tuberculosis versus sarcoidosis persists in regions with high prevalence of tuberculosis. However, EUS‐FNA is useful in diagnosing unsuspected malignancies and confirming the presence of granulomatous lymphadenitis. Diagn. Cytopathol. 2013; 41:1019–1022.© 2011 Wiley Periodicals, Inc.