Dialysis crystalline arthropathy: an entity underrecognized pathologically.
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Arthritis↗
Biomedical subjects
L J Layfield
Publications and source records attributed to L J Layfield.
Immediate on-site interpretation of fine-needle aspiration smears: a cost and compensation analysis.
BACKGROUND: A significant body of literature exists supporting the cost effectiveness of fine-needle aspiration (FNA) cytology in the work-up of patients with potential neoplastic disease. Several authorities have stated that immediate, on-site smear evaluation by cytopathologists optimizes diagnostic accuracy and minimizes the technique's insufficiency rate. This favorable effect on FNA diagnostic accuracy is most pronounced for deep body sites, where FNA is guided by computed tomography (CT), ultrasound, bronchoscopy, or endoscopy. Little data exist regarding whether compensation from Medicare is adequate to support the pathologist in this endeavor compared with other potentially more remunerative activities, including routine surgical pathology sign-out, nongynecologic cytopathology sign-out, and frozen section consultation. METHODS: The authors studied a series of 142 fine-needle aspirates with immediate, on-site evaluations performed under a variety of clinical settings. These included bronchoscopic, endoscopic, ultrasound-guided, and CT-guided biopsies along with palpation-directed biopsies performed by either cytopathologists or clinicians. For these aspirates, total pathologist attendance time was calculated and correlated with guidance technique, target organ, location where aspirate was performed, and nature of aspirator. Fifty frozen section evaluations were timed similarly. For comparison purposes, cytopathologists' costs were calculated using the 80th percentile pay level of an associate professor with full-time clinical duties. Medicare rate schedules were used to calculate compensation. Including salary and benefits, the pathologist cost was approximately $88.83 per hour. RESULTS: On average, an intraprocedural FNA evaluation for a CT-guided biopsy required 48.7 minutes, an ultrasound-guided biopsy required 44.4 minutes of pathologist time, an endoscopic procedure required 56.2 minutes, a bronchoscopic procedure required 55.3 minutes, a clinic aspirate performed by a pathologist required 42.5 minutes, and a clinic FNA performed by a clinician required 34.7 minutes. The average frozen section required 15.7 minutes of pathologist time for performance and interpretation. With the exception of FNA performed in clinic by the cytopathologist, time costs exceeded compensation by $40-50 per procedure. Clinic aspirates performed by a clinician and immediately evaluated by a pathologist resulted in a deficit of approximately $18 over actual time cost. CONCLUSIONS: From the current data, it appears that intraprocedural consultations by cytopathologists for CT-guided, ultrasound-guided, bronchoscopic, or endoscopic procedures are compensated insufficiently by current Medicare compensation schedules using the CPT code 88172 for on-site evaluation. Only when the cytopathologist personally performs the aspirate and immediately interprets it (CPT codes 88172 and 88170) does the Medicare payment adequately compensate for professional services.
Biopsy, Needle↗
Significance of lymphoglandular bodies in bone marrow aspiration smears.
The presence of lymphoglandular bodies (LGB) or Söderström bodies is often stated to be a feature of lymphoid processes. In our experience, LGB are typically identified in B-cell processes but not in T-cell lymphomas or myeloid leukemias. We reviewed 136 bone marrow aspirate smears. The number of LGB per five high-power fields was counted, and median counts for B-cell processes, non-B-cell processes, myeloid leukemias, and T-cell malignancies were obtained and compared by the Wilcoxon rank sum test. Bone marrow aspirate smears involved with B-cell malignancies contained a median of 30 (range, 1-250) LGB per five high-power fields. Compared to myeloid leukemias (median, 11; range, 1-253) and T-cell malignancies (median, 7; range, 0-41), the differences were statistically significant (P < 0.001 and P = 0.01, respectively). While lymphoglandular bodies can be seen in a variety of malignant hematopoietic and nonhematopoietic disorders, they are found in significantly greater numbers in B-cell malignancies.
Biopsy, Needle↗
Fine-needle aspiration biopsy of alveolar rhabdomyosarcoma of the parotid: a case report and review of the literature.
The cytologic features of an alveolar rhabdomyosarcoma arising within the parotid gland are described. The occurrence of this neoplasm as a primary malignancy in the parotid gland is very rare, and the tumor is usually not included in the cytologic differential diagnosis of parotid tumors. The diagnosis of the current case was achieved by a combination of fine-needle aspiration biopsy and frozen sections. Realizing the difficulty of recognizing this tumor both histologically and cytologically, we present this case to increase the awareness of this tumor's occurrence within the parotid gland and other salivary glands, and to highlight cytomorphologic features that will aid the pathologist in making the correct diagnosis.
Adult↗
Atypical squamous epithelium in cytologic specimens from the pancreas: cytological differential diagnosis and clinical implications.
Atypical squamous epithelium is an uncommon finding in cytologic specimens obtained from pancreatic lesions. A variety of pathologic conditions can result in the presence of these cells, including primary or metastatic carcinomas, chronic pancreatitis, and squamous metaplasia related to pancreatic or biliary duct stent placement. Primary adenosquamous and squamous-cell carcinomas of the pancreas are rare, representing 3.4% and 1.4 % of pancreatic carcinomas, respectively. Cytologic separation of these malignancies from less ominous metaplasias has immense clinical importance. We reviewed Indiana University Hospital's and Duke University's experiences with atypical squamous epithelium occurring within pancreatic aspirates. Study cases were identified using a computer to search the cytology records of these two institutions. Nine cases with a diagnosis of squamous-cell carcinoma, adenosquamous carcinoma, or atypical squamous epithelium were retrieved from the two institutions' Department of Pathology files. One case of pure squamous-cell carcinoma occurred in a patient with a known pulmonary primary; a single case of adenosquamous carcinoma was diagnosed in a patient with a coexistent endometrial primary; a single sample of adenocarcinoma with squamous differentiation was diagnosed in a patient without other known disease; and four primary squamous-cell carcinomas of the pancreas were detected. In addition, a single case of atypical squamous metaplasia associated with a stent was identified, and one case of atypical squamous epithelium associated with chronic pancreatitis was diagnosed. Despite the reactive atypia present in the examples of metaplastic squamous epithelium, separation of these cases from true squamous-cell carcinoma and adenosquamous carcinoma was achievable by cytologic evaluation. No cytologic criteria aided in separating primary pancreatic carcinomas with squamous differentiation from metastatic lesions. In this study, we report our findings in a series of nine cases where cytology disclosed atypical squamous epithelium in the aspirates derived from pancreatic lesions.
Carcinoma, Adenosquamous↗
Malignant islet cell tumor with sarcomatous differentiation.
Malignant mesenchymal neoplasms of the pancreas are rare and malignant islet cell tumors with sarcomatous dedifferentiation are rarer still. We present a case of malignant islet cell tumor with sarcomatous differentiation, which to our knowledge is only the second reported case showing such a combination of morphologic features. Clinically, the neoplasm was not hormonally active and immunohistochemical staining was negative for gastrin, glucagon, insulin and somatostatin. The sarcomatous component strongly reacted with an antibody directed against vimentin, and a minority of cells stained strongly with antisera directed against desmin and smooth muscle actin. The spindle cell component was nonreactive with antibodies directed against Factor VIII. The myogenous direction of differentiation in the present tumor is similar to that seen in the prior case report of malignant islet cell tumor with rhabdomyosarcomatous differentiation.
Actins↗
A comparison of touch imprint cytology and Mohs frozen-section histology in the evaluation of Mohs micrographic surgical margins.
BACKGROUND: Touch imprint cytology (TIC) is commonly used in the diagnosis of tumors and has been applied to margin analysis of breast lumpectomy specimens with good success. OBJECTIVE: Our purpose was to determine the diagnostic adequacy of TIC for identifying positive and negative Mohs surgical margins for basal cell carcinoma (BCC) excisions, compared with the "gold" standard, Mohs tangential sectioning. METHODS: Fifty-eight patients undergoing 69 Mohs micrographic surgical procedures for biopsy-proven BCC were included in this study between October 1998 and January 1999. Patients were excluded if the neoplasms were of another histologic type, including BCCs with squamous features. One hundred sixty-six touch imprint slides were prepared from 166 fragments of skin tissue excised during MMS. Touch imprint slides were evaluated blindly and independently by two pathologists, one of whom was also a cytopathologist. The slides were diagnosed as positive for tumor, negative for tumor, or, rarely, atypical but suspect for tumor. Discrepancies between the pathologists' interpretations were re-evaluated with the use of a two-headed microscope and a consensus was reached. After all cytologic interpretation was completed, the results were compared with the histologic diagnosis rendered for each fragment of tissue by the Mohs surgeon. RESULTS: The prevalence of a positive margin by histologic confirmation was 55% overall, 60% for recurrent or sclerosing lesions, and 51% for nonsclerosing or recurrent lesions. The overall accuracy of this technique in identifying true positive and true negative margins was 71%. The sensitivity of TIC for identifying a positive margin was approximately 50% for all BCC types. The specificity was approximately 90% for all BCC types. CONCLUSION: TIC is inadequate for identifying positive margins compared with the "gold" standard, MMS.
Adult↗
A comparison of routine and rapid microwave tissue processing in a surgical pathology laboratory. Quality of histologic sections and advantages of microwave processing.
Rapid processing of histopathologic material is becoming increasingly desirable to fulfill the needs of clinicians treating acutely ill patients. Traditional techniques for rapid processing of paraffin-embedded tissues require 4 to 5 hours, delaying treatment for some critically ill patients and requiring additional shifts of technologists in the laboratory. Microwave processing further shortens this time, allowing even more rapid histopathologic diagnosis. Few data exist comparing quality of microwave-processed tissue with that processed by more traditional techniques. We randomly selected 158 paired specimens from 111 patients. One member of the pair was processed routinely overnight, while the other was processed by the rapid microwave technique. The slides then were compared for quality of histologic preparation in a blinded fashion by 2 pathologists. Eight routinely processed specimens were judged as suboptimal, while 6 microwave-processed specimens were judged as suboptimal and 1 was considered unsatisfactory for evaluation. In the remaining cases, the material obtained by the 2 techniques was considered of identical quality. Microwave processing considerably shortens the preparation time for permanent histologic sections without a demonstrable decrease in section quality or "readability."
Female↗
E-cadherin reactivity of 95 noninvasive ductal and lobular lesions of the breast. Implications for the interpretation of problematic lesions.
Studies suggest that E-cadherin is useful to classify epithelial breast lesions as ductal or lobular, but extensive experience with this antibody is lacking. We studied reactivity of lesions with classic and indeterminate morphologic features. We reviewed 95 lesions and divided them into unanimous and nonunanimous diagnosis groups; the unanimous group served as benchmark lesions to which E-cadherin reactivity could be standardized and compared. All 37 ductal lesions in the unanimous group had strong, diffuse E-cadherin reactivity. Two of 22 classic lobular carcinoma in situ (LCIS) lesions had sparse E-cadherin-reactive lobular cells within a few terminal duct lobular units. Neither displayed transition from nonreactive to reactive cells. Of 36 lesions in the nonunanimous group, 19 had insufficient morphologic features for definitive classification. Only 6 of 19 were E-cadherin reactive, including several minimally proliferative lesions. The other 17 lesions in the nonunanimous group had LCIS and ductal carcinoma in situ (DCIS) features. All had no E-cadherin, or strong membrane reactivity of constituent cells in varying proportions, without a transition between reactive and nonreactive cells. Results suggest that the majority of morphologically nondiagnostic atypical lesions are lobular, including those associated with DCIS. E-cadherin seems to be absent in most lobular lesions.
Benchmarking↗
Fine-needle aspiration cytology: a survey of current utilization in relationship to hospital size, surgical pathology volume, and institution type.
Fine-needle aspiration cytology has become an accepted technique for the preoperative diagnosis of palpable and radiographically detected lesions at a wide variety of body sites. Little information exists regarding the degree of utilization of the technique in the general medical community. The present study investigated the number of fine-needle aspirations (FNAs) performed in relationship to hospital size, surgical pathology caseload, and type of hospital. Six hospitals from each state were selected at random (total of 300), and a survey was sent which requested the following information: hospital size, surgical pathology caseload, FNA volume, most common sites aspirated, change in FNA utilization over the last 5 years, and who was performing the needle aspirates. Usable responses were received from 133 institutions. The survey revealed that in 63% of institutions, FNAs were performed predominantly or exclusively by clinicians. An increase in number of FNAs performed was reported in 73% of institutions, while 11% reported a net decrease in FNA volume. The breast was the most common organ undergoing needle aspiration, followed by the thyroid and lung. For all hospitals, irrespective of size and type, FNA volume represented about 2.5% of the total surgical pathology volume. For nonacademic tertiary-care institutions, FNA represented approximately 1.2% of the surgical pathology caseload, and for academic tertiary-care institutions, FNA volume was approximately 3.6% of cases. The survey indicated that utilization of FNA continues to increase, is predominantly performed by clinicians, and represents a greater percentage of tissue examinations in academic tertiary-care institutions than in either community general hospitals or nonacademic tertiary-care institutions.
Biopsy, Needle↗
Fine-needle aspiration findings in nodular myositis: a case report.
Fine-needle aspiration (FNA) is frequently the initial diagnostic modality for the workup of suspected metastatic disease in subcutaneous or deeper soft tissues. The technique is less well-accepted for the diagnosis of primary soft-tissue lesions. Occasionally during the investigation of suspected metastatic disease, primary processes of the soft tissues will undergo FNA. Thus, familiarity with the cytomorphology of soft-tissue reparative and neoplastic lesions is important. A variety of reparative and degenerative entities exist within the soft tissues, one of which is localized nodular myositis. This lesion may be a precursor of generalized polymyositis, including polymyositis associated with graft vs. host disease, or it may remain a localized process. Aspirates from localized nodular myositis demonstrate fragments of striated muscle including degenerating and regenerative myocytes, a mixed inflammatory background, and necrotic debris. Cytologic identification of this lesion can be therapeutically important, particularly in post-bone marrow transplant patients.
Adult↗
Insular carcinoma of the thyroid: report of a case with intact insulae and microfollicular structures.
A case of insular carcinoma of the thyroid is presented, in which a prominence of microfollicular structures resulted in difficulty in distinguishing it from a follicular neoplasm of the thyroid. The patient presented with a single discrete thyroid nodule, aspiration of which yielded markedly cellular smears containing cells lying singly, in tight clusters and microfollicles. Criteria for separation of insular carcinoma of the thyroid from follicular neoplasms include the presence of intact insulae, high cellularity, and the presence of small amounts of necrotic debris.
Adenocarcinoma↗
Macrodystrophia lipomatosa with associated fibrolipomatous hamartoma of the median nerve.
Macrodystrophia lipomatosa (MDL) is a rare disease typically causing localized gigantism and is often associated with a fibrolipomatous hamartoma (FH) of the median or plantar nerve. A previously unreported case of MDL with associated FH of the median nerve is presented.
Child, Preschool↗
Abstracts. Mod Pathol 2000;13:17A,19A,22A,24A,25A,27A.
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Adenocarcinoma↗
Prevalence of inter-institutional anatomic pathology slide review: a survey of current practice.
Multiple studies have demonstrated discrepancy rates between original and review histopathologic diagnoses of up to 30% with a mean of approximately 10%. In view of these rates of discrepancy, several authorities, including the Association of Directors of Anatomic and Surgical Pathology, have recommended in-house review of all outside materials before commencement of therapy. We used a mail survey to determine the degree of compliance with these recommendations among pathology groups in the United States. Mail surveys were sent to six randomly selected hospitals from each state (300 total). The survey included demographic questions, including surgical pathology caseload, size of hospital (beds), and type of hospital (community-general, non-academic-tertiary care, or academic-tertiary care). The survey asked whether the hospital required review of all outside slides before the performance of surgery. If not, was such a policy encouraged but not required. The survey also asked whether in-house review of outside cases had disclosed any significant differences in pathologic diagnoses. Finally, the survey questioned whether any discrepancies between an internal and external surgical pathology diagnosis had been discovered following radical surgery. One hundred twenty-six usable responses were obtained. Fifty-five of these were from hospitals self-described as community-general, seven were from hospitals describing themselves as non-academic-tertiary care, and the remaining 61 hospitals described themselves as academic-tertiary care institutions. Sixty-three institutions stated they had a requirement for in-house review of outside material, with 46 of 61 academic-tertiary centers having such a requirement. Thirty-seven of 55 community-general hospitals did not require in-house review of outside material before surgery could be performed. One hundred ten of the 126 institutions returning surveys either encouraged or required review of outside material. Ninety-five institutions reported that they had at least one outside case in which their diagnosis was significantly discordant with that rendered by the referring pathologist. Sixty (48%) of the 126 institutions reported at least one case in which a discrepancy was found between the outside biopsy diagnosis and the internal diagnosis rendered on material obtained by radical surgery. Approximately half of all responding institutions have a requirement for in-house review of outside material prior to surgery. A majority of institutions requiring such review have found discrepancies between the in-house diagnoses and those rendered by referring laboratories.
Diagnostic Errors↗
Mucoepidermoid carcinoma arising in the glans penis.
Mixed carcinoma (squamous and glandular) of the penis is a rare neoplasm with an unknown origin and a poorly defined prognosis. The mucoepidermoid carcinoma described herein has not been previously reported to our knowledge. The present carcinoma arose from and extensively ulcerated the squamous epithelium of the glans penis, including that surrounding the urethral meatus. The neoplasm was composed of well-differentiated nonkeratinizing squamous cell carcinoma associated with large areas of carcinoma formed by cell nests that contained poorly differentiated squamous elements and large eosinophilic to pale granular cells. Mucin stains revealed approximately one quarter of the pale cells contained mucous substances. These findings are virtually identical to the mucoepidermoid type of carcinoma seen in the cervix. The 3 previously reported cases of adenosquamous carcinoma of the penis demonstrated a relatively indolent course, with only one being associated with a single inguinal lymph node metastasis. That patient was alive and well 9 years following diagnosis. Our example of mucoepidermoid carcinoma appears to demonstrate a more aggressive course than those reported previously.
Carcinoma, Mucoepidermoid↗
Uterine smooth muscle tumors: utility of classification by proliferation, ploidy, and prognostic markers versus traditional histopathology.
CONTEXT: Accurate categorization of uterine smooth muscle neoplasms by light microscopic examination is difficult. Multiple classification schemes have been proposed based on mitotic rate, nuclear atypia, and the presence or absence of necrosis. None of these classification systems has been entirely successful. Multiple ancillary techniques have been tested for their ability to predict behavior of uterine smooth muscle tumors. OBJECTIVE: We assayed 45 smooth muscle neoplasms for a variety of proliferation markers, oncogene protein products, and DNA ploidy level to determine if these markers supplied prognostically useful information over and above that obtained by routine light microscopic assessment. STUDY DESIGN: Forty-five uterine smooth muscle neoplasms were assessed for DNA ploidy; silver-staining nucleolar organizer regions (AgNORs); percent nuclear proliferating cell nuclear antigen (PCNA); expression of p53, Her-2/neu, and MDM-2 protein; mitotic rate; and nuclear grade. These markers were correlated with histologic diagnosis and the occurrence of a clinically adverse event (death, metastasis, or recurrence). RESULTS: Diagnostic category (P <.001), nuclear grade (P <.002), mitotic activity (P <.001), mean AgNORs (P <.001), percent nuclear PCNA (P =.02), and expression of p53 (P =.02) all correlated with clinical outcome. No statistically significant correlation between clinical outcome and the categories MDM-2 expression, Her-2/neu expression, or DNA ploidy was seen. Nuclear grade, p53 expression, mitotic rate, AgNORs, and percent nuclear PCNA correlated with diagnosis. CONCLUSIONS: Diagnostic category, mitotic rate, AgNOR counts, PCNA, and p53 expression dichotomized uterine smooth muscle neoplasms into prognostically favorable and unfavorable groups. Although highly significant, the category AgNORs was no more successful than mitotic rate in dividing uterine smooth muscle neoplasms into prognostically favorable and unfavorable groups. Expression of p53 and percent nuclear PCNA dichotomized uterine smooth muscle neoplasms into prognostic groups, but neither technique reached the level of significance achieved by mitotic rate. Our data indicate that mitotic rate and the classification system of Kempson and Bari are at least as effective as the tested markers in separating uterine smooth muscle neoplasms into prognostic categories.
Aneuploidy↗
Malignant giant cell tumor of synovium (malignant pigmented villonodular synovitis).
CONTEXT: Pigmented villonodular synovitis (PVNS) is a well-recognized entity that has the potential for extensive local destruction, even though it rarely metastasizes. Rare reports of malignant forms are recorded in the literature. We observed 2 patients in whom examples of PVNS followed an aggressive course with multiple recurrences, metastasis, or degeneration to an appearance resembling malignant fibrous histiocytoma. OBJECTIVE: We studied the occurrence and persistence of aneuploidy for chromosomes 5 and 7 in 2 patients with clinically aggressive PVNS. DESIGN: Fluorescence in situ hybridization was performed for the detection of chromosomes 5 and 7 in the primary lesions, recurrences, and metastases in 2 examples of PVNS. RESULTS: Fluorescence in situ hybridization demonstrated small but significant numbers of cells with trisomies for chromosomes 7 and/or 5 in both the primary and recurrent lesions of both patients. CONCLUSIONS: The presence of consistent chromosomal trisomies (5 and 7) in both patients' examples of PVNS suggests a neoplastic nature for this lesion. The persistence of these trisomies in the primary lesions, recurrences, and metastases supports a molecular link between the primaries, recurrences, and metastases despite changes in morphologic features. The presence of persistent trisomies in the recurrent and metastatic lesions supports the concept of malignant PVNS.
Adult↗