Rhesus monkeys (Macaca mulatta) as a model for calcium pyrophosphate dihydrate crystal deposition disease

Calcium pyrophosphate dihydrate crystal deposition disease (CPDD) was recognized in 4 of 30 free-ranging rhesus macaques. By means of tissue radiography, focal radiodensities were noted in lumbar intervertebral discs, menisci, and articular cartilage. Crystal deposits were identified as calcium pyrophosphate dihydrate (Ca2P2O7 X 2H2O) by means of X-ray diffraction. The pathogenesis of calcium pyrophosphate dihydrate arthropathy in man remains elusive. However, with the recognition of this arthritis in a well defined population of aged nonhuman primates, a model now exists to facilitate the study of this disease.     

Cytopathologic features of pituitary carcinoma with cervical vertebral bone metastasis: a case report

BACKGROUND: Pituitary carcinomas are extremely rare tumors of the adenohypophysis. The presence of craniospinal and/or systemic extracranial metastases is the only reliable criterion for the diagnosis of pituitary carcinoma. To date, only 2 cases have been reported correctly by fine needle aspiration biopsy (FNAB). We present an additional case of pituitary carcinoma with FNAB features. CASE: A 60-year-old woman presented with clinical features of Cushing's disease and a pituitary tumor. She underwent transsphenoidal resection of the tumor. The initial diagnosis was an adrenocorticotrophic hormone (ACTH)-producing invasive pituitary adenoma. The patient presented again with neck pain 6 years after the operation. Magnetic resonance imaging revealed metastatic tumor masses at the level of C5-C6 of the cervical vertebrae. Intraoperative fine needle aspiration and incomplete excision of metastatic tumors were performed. Cytologically, tumor cells were composed of a combination of loose groups and single cells. Neoplastic cells had a relatively monotonous appearance and displayed characteristic neuroendocrine tumor features. Immunocytochemistry from cell block sections revealed AE1/ AE3, synaptophysin chromogranin A and ACTH positivity in the tumor cells. CONCLUSION: Pituitary carcinoma with extracranial systemic metastases demonstrates typical neuroendocrine features on fine needle aspiration. In the differential diagnosis, metastatic neuroendocrine carcinomas should be kept in mind. In the absence of sufficient clinical data, these 2 entities cannot be distinguished correctly through the cytologic features.     

Fine needle aspiration of Actinomyces infection of the breast. A novel presentation of thoracopleural actinomycosis.

A case of Actinomyces infection of the breast secondary to thoracopleural disease was initially diagnosed by fine needle aspiration biopsy. The tender, hard, swollen left breast was clinically suspected of harboring an inflammatory carcinoma. Cell block sections of the aspirate showed polymorphonuclear leukocytes surrounding a typical "sulphur granule" composed of branching filaments. The diagnosis was confirmed by culture of material obtained at subsequent surgery.     

Fine needle aspiration of tophi for crystal identification in problematic cases of gout. A report of two cases

BACKGROUND: The definitive diagnosis of gout is best established by demonstration of monosodium urate (MSU) crystals in the synovial fluid or biopsy. Fine needle aspiration cytology (FNAC) of tophi can play a crucial role in diagnosis. CASES: A 36-year-old chronic alcoholic male developed subcutaneous nodules on both malleoli without a history of arthropathy and with normal serum uric acid levels. FNAC of the nodules demonstrated stacks and sheaves of needle-shaped crystals of MSU. A 50-year-old diabetic male developed multiple nodules on the feet. He gave a past history of painful athropathy. A roentgenogram of the feet was suspicious for gout; however, joint aspiration failed, and the serum uric acid levels were normal. At this juncture FNAC of the feet tophi clinched the diagnosis of gout. In both cases, polarization of needle washings (wet mount) and the fixed, Papanicolaoustained smears showed negatively birefringent, needle-shaped crystals of MSU, thus confirming the diagnosis of gout. CONCLUSION: FNAC of gouty tophi is an easy alternative to synovial biopsy and joint fluid analysis. It is simpler, easier and less painful. As crystals are preserved in stained smears, they can be employed for polarization and confirmation of gout.     

Refinement of the chromosome 5p locus for familial calcium pyrophosphate dihydrate deposition disease.

Familial calcium pyrophosphate dihydrate deposition disease (CPPDD) is a disease of articular cartilage that is radiographically characterized by chondrocalcinosis due to the deposition of calcium-containing crystals in affected joints. We have documented the disease in an Argentinean kindred of northern Italian ancestry and in a French kindred from the Alsace region. Both families presented with a common phenotype including early age at onset and deposition of crystals of calcium pyrophosphate dihydrate in a similar pattern of affected joints. Affected family members were karyotypically normal. Linkage to the short arm of chromosome 5 was observed, consistent with a previous report of linkage of the CPPDD phenotype in a large British kindred to the 5p15 region. However, recombinants in the Argentinean kindred have enabled us to designate a region<1 cM in length between the markers D5S416 and D5S2114 as the CPPDD locus.     

Cytologic diagnosis of tumoral calcinosis: a case report

A 55-year-old male with end-stage renal disease on hemodialysis presented with neck pain of 1 year's duration. A computed tomography (CT) scan was performed as part of his workup, and a posterior cervical neck mass was detected. CT-guided fine needle aspiration was performed with an immediate cytologic interpretation of tumoral calcinosis. On air-dried Diff-Quik and alcohol-fixed Papanicolaou-stained smears, the specimen demonstrated coarse-to-fine calcific debris. A final diagnosis of tumoral calcinosis was rendered. A literature search revealed that this diagnosis is rarely made by touch imprint cytology of core needle biopsy and/or needle aspiration cytology, although it can be a relatively easy and straightforward diagnosis.     

Fine needle aspiration biopsy of a hepatic mass. An example of a near error

Material obtained by fine needle aspiration (FNA) from a hepatic mass showed conflicting features in Papanicolaou-stained smears and hematoxylin-and-eosin-stained cell block sections. A sarcomatous lesion (metastatic pleomorphic liposarcoma) was suggested by the smears while the cell block sections revealed the lesion to be a lipid-rich hepatocellular carcinoma. The nature of this apparent discrepancy is discussed.     

Comparative validation of c-kit exon 11 mutation analysis on cytology samples and corresponding surgical resections of gastrointestinal stromal tumours

Objective:  Studies have shown that c-kit mutation analysis of gastrointestinal stromal tumours (GISTs) obtained by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) can be routinely performed. We validated c-kit exon 11 mutational analysis on cell block material obtained from fine needle aspiration cytology (FNAC) for diagnostic purposes and compared it with the same analysis in formalin-fixed paraffin-embedded full sections of the corresponding resection specimens.
Methods:  c-kit mutation analysis was done on cell block material obtained from ten cases encountered in our department from 1999 to 2008 on which FNAC was attempted pre-operatively. The findings were compared with analysis on full paraffin section of the corresponding resected tumours in seven cases where patients opted for resection. c-kit exon 11 was examined via bidirectional nucleic acid sequencing.
Results:  Our results showed 100% concordance for the presence and type of exon 11 mutation in the resected and aspirated tumours in all seven cases. These mutations had diagnostic value when compared with other neoplasms that are part of the cytomorphological differential diagnosis, such as leiomyosarcoma or gastric adenocarcinomas.
Conclusion:  Molecular cytopathology is a powerful tool that can complement morphology and immunohistochemical assessment of cytological material in routine practice for the diagnosis and prognostication of GISTs. We briefly discuss the advantages and limitations of the fine needle method of obtaining tissue for the diagnosis and prognostication of GISTs, and its current therapeutic strategies.     

Cotton block method: one-step method of cell block preparation after fine needle aspiration

OBJECTIVE: To describe the cotton block method, an easy, inexpensive, 1-step method of obtaining a cell block after fine needle aspiration biopsy. STUDY DESIGN: Before connection to a 10-mL syringe, the plastic hub of a 22-23-gauge needle is filled with the 3-4-mm, woolly tip of a cotton bud. Aspiration is performed as described elsewhere. After smear preparation, the material remaining in the needle and the material retained in the cotton wool mesh are immediately fixed by aspiration ofa fixative fluid (70% alcoholic formaldehyde-acetic acid). After fixation, the cotton tip is removed and routinely processed for paraffin embedding, and the sections are stained by routine methods used in cytopathology. RESULTS: The results demonstrate that the amount and quality of material obtained in the cotton wool tip is similar to that in the traditional cell block obtained from the pellet after centrifugation of aspirated fluid. CONCLUSION: The method is easy to perform and cost effective and is a rapid way to prepare cell blocks of high quality, allowing special staining techniques and improving cytohistologic correlation.     

Extradural spinal meningioma as a source of plasmacytoid cells. A case report

BACKGROUND: Meningiomas, tumors that often affect middle-aged and elderly people, occasionally arise in the spine, typically at the thoracic level. The cytologic findings in meningiomas include whorls and syncytial clusters of bland-looking cells with scattered, psammomatous calcifications and intranudclear cytoplasmic inclusions. However, in many cases, not all these findings are seen, and in rare cases, unusual cytomorphologic features are observed. CASE: A case of spinal meningioma was located in the extradural compartment and composed predominantly of singly scattered cells with a plasmacytoid appearance, demonstrated on fine needle aspiration biopsy smear preparations. The cell block showed more typical features of meningioma, and the diagnosis was supported by the results of immunohistochemical staining. CONCLUSION: The diagnosis of spinal meningioma is readily made by employing magnetic resonance imaging. The diagnosis can be difficult to confirm pathologically when atypical histologic findings are present, as in this case, with prominent plasmacytoid features. Sections from the cell block and immunohistochemical stains as well as clinical and radiologic findings were extremely helpful in arriving at the final diagnosis.     

Malignant phyllodes tumor metastatic to the lung with osteogenic differentiation diagnosed on fine needle aspiration biopsy. A case report

BACKGROUND: Osteosarcomatous differentiation in malignant phyllodes tumors is rare. No cases of either primary or metastatic lesions were identified in the literature that were initially diagnosed on fine needle aspiration biopsy. CASE: Cytologic and histologic findings of a metastatic malignant phyllodes tumor with osteosarcomatous differentiation in a 63-year-old woman are presented. This case was diagnosed initially on fine needle aspiration biopsy and confirmed with histologic examination of the pulmonary lesion. CONCLUSION: Although rare, the differential diagnosis of metastatic phyllodes tumor should be considered in the appropriate clinical setting when examining a pleomorphic spindle cell tumor with heterologous elements on fine needle aspiration biopsy.     

Kikuchi's histiocytic necrotizing lymphadenitis. Diagnosis by fine needle aspiration

Two cases of Kikuchi's histiocytic necrotizing lymphadenitis diagnosed by fine needle aspiration (FNA) of enlarged lymph nodes are reported. The FNA smears contained randomly activated lymphoid cells, necrotic debris, karyorrhectic cells and prominent histiocytes, suggesting the presence of reactive lymph nodes. The true nature of the lesions was evident from the examination of cell block sections prepared from tissue fragments in the aspirates, which preserved the architectural relationships of the different cell types. The same patterns were found in retrospectively and subsequently examined excised lymph nodes from these cases. The differential diagnosis of this entity, which may simulate a malignant lymphoma because of the presence of large numbers of activated lymphoid cells, is discussed and the value of preparing FNA cell blocks is emphasized. Though this rare benign disease may be suspected clinically in the more typical cases, such as young women with cervical lymphadenopathy, fever, neutropenia and otherwise excellent condition, the diagnosis cannot be made without a lymph node biopsy, which FNA may be able to provide in some instances.     

Transthoracic needle aspiration biopsy in Wegener's granulomatosis. Morphologic findings in five cases

Percutaneous needle aspiration biopsies of the lung from five patients with Wegener's granulomatosis were reviewed. Three of the patients presented with the generalized form of the disease while two presented with the limited pulmonary form; one of the latter subsequently developed disseminated disease. The morphologic findings in the pulmonary aspirates were similar in all cases. The cytologic preparations contained neutrophils entrapped within necrotic debris plus scattered but prominent histiocytic giant cells, which often had nuclei arranged in rings or horseshoes, in a background of lymphocytes, epithelioid histiocytes and reactive pneumocytes. Cell block preparations showed discrete areas of necrosis containing a neutrophilic infiltrate and focally palisaded by epithelioid histiocytes. The intervening viable tissue contained prominent histiocytic giant cells and chronic inflammatory cells enmeshed in a fibrous matrix. One cell block contained a small artery with a small focus of possible granulomatous arteritis. While an open lung biopsy is generally required for a definitive diagnosis, the pathologist may encounter unsuspected Wegener's granulomatosis in a needle aspirate. Recognition of the findings observed in these cases should alert the pathologist to the possibility of Wegener's granulomatosis so that an open lung biopsy can be performed if clinically indicated and cytotoxic therapy can be promptly instituted if the diagnosis of this entity is confirmed.     

The gray zone in breast fine needle aspiration cytology. How to report on it?

OBJECTIVE: To study the "gray zone" in breast fine needle aspiration cytology in which an unequivocal diagnosis cannot be reached with fine needle aspiration cytology findings. STUDY DESIGN: This study compared cytology and histopathology of 72 breast lesions in which an initial cytologic diagnosis of atypia was given. RESULTS: There were 36 benign (50%) and 36 malignant (50%) histologic biopsy cases in the cytologic atypia group. Anisonucleosis, chromatin and nuclear membrane irregularity, and presence of myoepithelial cells were significantly different in benign and malignant cases. CONCLUSION: The gray zone in breast fine needle aspiration cytology is a broad spectrum that changes from proliferative fibrocystic disease to sclerosing adenosis to malignancy. Diagnosing gray zone pathology as atypical in fine needle aspiration cytology causes no delay in treatment as excisional biopsy is recommended for all equivocal cases.     

Invasive cervical thymoma masquerading as a solitary thyroid nodule. Report of a case studied by fine needle aspiration

A 49-year-old woman underwent fine needle aspiration (FNA) biopsy of a presumed thyroid nodule. The initial cytopathologic interpretation suggested a chronic lymphocytic thyroiditis or a malignant lymphoma. The examination of frozen sections during surgery also suggested the presence of a lymphoma. However, histopathologic examination of permanent sections showed the lesion to be an invasive ectopic lymphocyte-predominant thymoma adjacent to the thyroid. Immunoperoxidase staining of FNA cell block sections and permanent sections showed positivity for keratin, proving the epithelial nature of the elongated and spindle-shaped tumor cells. This case high-lights the need to be aware of unusual lesions that may occur in the area of the thyroid; recognizing the potential diversity of "thyroid" masses that ultimately prove to be of nonthyroid origin should aid in making the correct cytologic differential diagnosis and interpretation of FNA samples obtained from such masses.     

Value of EUS‐FNA cytological preparations compared with cell block sections in the diagnosis of pancreatic solid tumours

Y. Kopelman, S. Marmor, I. Ashkenazi and Z. Fireman
Value of EUS‐FNA cytological preparations compared with cell block sections in the diagnosis of pancreatic solid tumours Objective: Endoscopic ultrasound‐guided fine needle aspiration (EUS‐FNA) is performed in order to achieve a definite tissue diagnosis of pancreatic lesions. This in turn is a guide to the appropriate treatment for the patient. Tissue samples collected by the same needle for cytological preparations and cell block histological sections (often referred to as FNA‐cytology and FNA–biopsy, respectively) are handled differently. The specific contribution of each of these tests was evaluated. Methods: One hundred and two consecutive patients underwent EUS‐FNA while being investigated for pancreatic solid lesions. Diagnosis was made by cytology, cell block sections or both. The diagnosis was confirmed by clinical outcome. Results: Male/female ratio was 61/41. Mean age was 65 ± 12 years (range, 22–94). Mean lesion size was 3.1 ± 1.8 cm (range, 0.6–10 cm); 68% were >2 cm and 75% were located in the pancreatic head. The average number of needle passes was two (range, 1–4 passes). Final tissue diagnosis was malignant in 66 (65%) patients. Sensitivity, specificity and accuracy were 73%, 94% and 81%, respectively, for cytology alone, and 63%, 100% and 78%, for cell blocks alone. Eighty‐two patients (80%) had cytology and cell blocks, which matched in 64 (78%) patients. EUS‐FNA results that relied on both techniques had 84% sensitivity, 94% specificity and 88% accuracy. Cytology revealed 13 malignancies not diagnosed on cell blocks, while cell blocks revealed five malignancies not diagnosed by cytology. Malignant lesions were more common in men; they were larger in size and located in the pancreatic head. Conclusion: EUS‐FNA cytology was more sensitive than cell blocks but less specific for the diagnosis of solid pancreatic lesions. The two methods are complementary and implementing both improves the diagnostic value of EUS‐FNA.     

P5L mutation in Ank results in an increase in extracellular inorganic pyrophosphate during proliferation and nonmineralizing hypertrophy in stably transduced ATDC5 cells

Ank is a multipass transmembrane protein that regulates the cellular transport of inorganic pyrophosphate. In the progressive ankylosis (ank) mouse, a premature termination mutation at glutamic acid 440 results in a phenotype characterized by inappropriate deposition of basic calcium phosphate crystals in skeletal tissues. Mutations in the amino terminus of ANKH, the human homolog of Ank, result in familial calcium pyrophosphate dihydrate deposition disease. It has been hypothesized that these mutations result in a gain-of-function with respect to the elaboration of extracellular inorganic pyrophosphate. To explore this issue in a mineralization-competent system, we stably transduced ATDC5 cells with wild-type Ank as well as with familial chondrocalcinosis-causing Ank mutations. We evaluated the elaboration of inorganic pyrophosphate, the activity of pyrophosphate-modulating enzymes, and the mineralization in the transduced cells. Expression of transduced protein was confirmed by quantitative real-time PCR and by ELISA. Levels of inorganic pyrophosphate were measured, as were the activities of nucleotide pyrophosphatase phosphodiesterase and alkaline phosphatase. We also evaluated the expression of markers of chondrocyte maturation and the nature of the mineralization phase elaborated by transduced cells. The cell line expressing the proline to leucine mutation at position 5 (P5L) consistently displayed higher levels of extracellular inorganic pyrophosphate and higher phosphodiesterase activity than the other transduced lines. During hypertrophy, however, extracellular inorganic pyrophosphate levels were modulated by alkaline phosphatase activity in this cell system, resulting in the deposition of basic calcium phosphate crystals only in all transduced cell lines. Cells overexpressing wild-type Ank displayed a higher level of expression of type X collagen than cells transduced with mutant Ank. Other markers of hypertrophy and terminal differentiation, such as alkaline phosphatase, osteopontin, and runx2, were not significantly different in cells expressing wild-type or mutant Ank in comparison with cells transduced with an empty vector or with untransduced cells. These results suggest that the P5L Ank mutant is capable of demonstrating a gain-of-function with respect to extracellular inorganic pyrophosphate elaboration, but this effect is modified by high levels of expression of alkaline phosphatase in ATDC5 cells during hypertrophy and terminal differentiation, resulting in the deposition of basic calcium phosphate crystals.     

P5L mutation in Ank results in an increase in extracellular inorganic pyrophosphate during proliferation and nonmineralizing hypertrophy in stably transduced ATDC5 cells

Ank is a multipass transmembrane protein that regulates the cellular transport of inorganic pyrophosphate. In the progressive ankylosis (ank) mouse, a premature termination mutation at glutamic acid 440 results in a phenotype characterized by inappropriate deposition of basic calcium phosphate crystals in skeletal tissues. Mutations in the amino terminus of ANKH, the human homolog of Ank, result in familial calcium pyrophosphate dihydrate deposition disease. It has been hypothesized that these mutations result in a gain-of-function with respect to the elaboration of extracellular inorganic pyrophosphate. To explore this issue in a mineralization-competent system, we stably transduced ATDC5 cells with wild-type Ank as well as with familial chondrocalcinosis-causing Ank mutations. We evaluated the elaboration of inorganic pyrophosphate, the activity of pyrophosphate-modulating enzymes, and the mineralization in the transduced cells. Expression of transduced protein was confirmed by quantitative real-time PCR and by ELISA. Levels of inorganic pyrophosphate were measured, as were the activities of nucleotide pyrophosphatase phosphodiesterase and alkaline phosphatase. We also evaluated the expression of markers of chondrocyte maturation and the nature of the mineralization phase elaborated by transduced cells. The cell line expressing the proline to leucine mutation at position 5 (P5L) consistently displayed higher levels of extracellular inorganic pyrophosphate and higher phosphodiesterase activity than the other transduced lines. During hypertrophy, however, extracellular inorganic pyrophosphate levels were modulated by alkaline phosphatase activity in this cell system, resulting in the deposition of basic calcium phosphate crystals only in all transduced cell lines. Cells overexpressing wild-type Ank displayed a higher level of expression of type X collagen than cells transduced with mutant Ank. Other markers of hypertrophy and terminal differentiation, such as alkaline phosphatase, osteopontin, and runx2, were not significantly different in cells expressing wild-type or mutant Ank in comparison with cells transduced with an empty vector or with untransduced cells. These results suggest that the P5L Ank mutant is capable of demonstrating a gain-of-function with respect to extracellular inorganic pyrophosphate elaboration, but this effect is modified by high levels of expression of alkaline phosphatase in ATDC5 cells during hypertrophy and terminal differentiation, resulting in the deposition of basic calcium phosphate crystals.     

Endoscopic ultrasonography-guided fine needle aspiration biopsy for staging malignant melanoma of the esophagus. A case report

BACKGROUND: Malignant melanoma (MM) rarely involves the esophagus. The outlook is dismal unless lesional tissue is limited to the esophageal wall. Hence, staging prior to extensive surgical intervention is desirable. CASE: A 54-year-old male presented with fatigue and melena. A diagnosis of MM primary in the esophagus was rendered on a biopsy of an esophageal polyp. The stage, determined by endoscopic ultrasonography-guided fine needle aspiration biopsy, was advanced. On the basis of this information, it was decided to spare the patient mutilating surgery. CONCLUSION: This report confirms the utility of endoscopic ultrasonography-guided fine needle aspiration biopsy in documenting the extent of lesions at sites difficult to access. Thus, management can be improved.     

Fine needle aspiration cytodiagnosis of liver tumors

OBJECTIVE: To present our experience with liver fine needle aspiration (FNA) diagnosis and the adjunctive use of cell blocks with reticulin stain. STUDY DESIGN: The authors reviewed the results of cytopathologic diagnosis obtained by FNA biopsy over a 1-year period, from January 2000 to December 2000, in patients who presented primarily with ultrasonographically suspected liver nodules. FNA smears from 936 patients and cell blocks from 796 patients were reviewed. RESULTS: Among the 936 aspirates studied, the most common malignancy was hepatocellular carcinoma (HCC), which was diagnosed in 427 cases (45.6%), followed by metastatic adenocarcinoma, with 52 cases (5.6%). The concurrent cell block was available in 796 cases. Among them, 574 (72.1%) contained sufficient tissue for diagnosis. Combining analysis of cytologic and histologic specimens, the sensitivity of ultrasound-guided FNA for diagnosis of liver tumors was 85.1% and the specificity 98.7%. The results were better than isolated cytologic analysis, which gave a sensitivity of 78.4% and specificity of 97.4%. The lower diagnostic accuracy of cytology resulted mainly from its lower ability to distinguish well-differentiated HCC from benign lesions. In the cell block sections with reticulin stain, all HCCs showed a decreased or absent reticulin pattern, whereas all the benign hepatocellular lesions usually had a normal trabecular reticulin framework. CONCLUSION: FNA cytology assisted by cell block examination can be an accurate and minimally invasive method for the definitive pathologic diagnosis of primary benign and malignant liver masses and for confirmation of tumors metastatic to the liver. In addition, reticulin staining should be part of the routine assessment of cell blocks. It enhances diagnostic accuracy, particularly for well-differentiated HCC.