cytology – Page 2 – Lablogatory

By the Book

One of my favorite parts of being a cytotechnologist is the delight of having cytology students rotate through our institution as a practicum site. The pandemic caused a clinical rotation hiatus for the safety of both our staff and students, but thanks to widespread healthcare vaccination, we were able to bring in some fresh minds to experience the variety of interesting cases we enjoy every day. I think what I love most about having students here is reminiscing of when I was in their shoes seven years ago. I remember going into my rotations using nothing but morphologic criteria I memorized from lecture and labs. My clinicals served as a rude awakening that we rarely see any textbook perfect cases. Cancer is like a shape-shifter – one melanoma looks entirely different than another. Two lung squamous cell carcinomas from the right upper lobes from two different patients could look entirely different. The unique variation within and between cancer types is what makes this field so beautifully fascinating. The first time a cytotechnology student shows me a case, tells me their thoughts, works through the criteria, and lists the differentials, I look up and say, “nothing is quite by the book.” How often we fall into a routine of relying on criteria, closing our minds to certain diagnoses because it doesn’t quite look like the clinical impression. When the pathologic and clinical impressions divide, more diagnostic tests are performed, CPT codes fill our billing tab, and we start to panic. “It’s supposed to be adenocarcinoma, so why doesn’t it look like adenocarcinoma?!?

A few weeks ago, the lab received a left pleural fluid from a patient who presented with a history of small cell cervical cancer. I remember learning about this in my first semester of grad school – how rare a finding of small cell carcinoma is, accounting for less than 5% of cervical cancers. It essentially mimics small cell carcinoma of the lung and other neuroendocrine carcinomas, where you should be able to identify the telltale salt-and-pepper chromatin, nuclear molding, scant cytoplasm, loosely cohesive or isolated, necrosis, usually an absence of nucleoli, a high proliferation index with mitotic figures, etc. It’s an aggressive disease to say the least, just like its lung counterpart. When this cancer metastasizes, it takes its same characteristics with it, spreading rapidly without care.

The first step in processing a fluid is to prepare a fresh, air-dried, Diff-Quik-stained cytospin to triage the specimen and decide whether the specimen should be processed routinely or hand-prepped and stained with overtly positive fluids to prevent cross-contamination. There was one cluster identified on the Diff-Quik preparation, but compared to the background of mesothelial and inflammatory cells, the tumor content was insufficient to push it up to hand-processing. The bluish cytoplasm caught my attention as a feature of neuroendocrine tumors AND lymphomas, but the nuclear molding had me favoring neuroendocrine.

Image 1. Pleural fluid, left. DQ-stained cytospin.

That afternoon, I examined the pap-stained smears and SurePath liquid-based preparation, identifying similar cells of interest. However, despite the presence of nuclear molding and scant cytoplasm, the nuclei presented with prominent nucleoli. An interesting feature, to say the least.

Images 2-5. Pleural fluid, left. 2-3, Pap-stained smears (2, lightened to highlight nucleoli); 4-5, Pap-stained SurePath liquid-based preparation.

The following morning, I screened the cell block slides and came across molded groups of cells (appearing as a garden aerial view). Still the prominent nucleoli baffled me, and I thought, “Why doesn’t this look like a classic small cell carcinoma? They clinical history even included known lung mets from the patient’s small cell cervical cancer!”

Images 6 and 7: pleural fluid, left. 6, H&E cell block section 100X; 7, H&E cell block section 400X.

When I sent the case for review by the pathologist, I wrote up a diagnosis of Positive for Malignant Cells; Carcinoma, small cell? Recommend correlation with IHC.” My attending was just as intrigued. She ordered a thorough panel of immunohistochemistry stains based on the morphologic findings.

Images 8-11. Pleural fluid, left. 8, synaptophysin+; 9, CD56+; 10, TTF-1+; 11, BerEP4+.

The tumor cells are positive for synaptophysin, CD56, TTF-1, and BerEP4, focally positive for CK7 and chromogranin (not shown), and negative for calretinin, PAX-8, and p40 (also not shown). The findings support the diagnosis of metastatic high grade carcinoma with neuroendocrine differentiation.

While the stains support a diagnosis of small cell carcinoma, the morphologic diagnosis was mildly questionable. I went back to the patient’s record to see what we may have missed in the clinical history. It turns out the patient initially presented with Stage IB2 HPV+, moderately-differentiated cervical adenocarcinoma in 2020. After completing brachytherapy and one cycle of chemotherapy, but could not tolerate additional treatments due to leukopenia and elevated LFTs. Shortly thereafter the patient complained of abdominal pain and a liver mass and bulky lymphadenopathy were identified on imaging. An FNA of a supraclavicular lymph node confirmed not only metastasis of the patient’s cervical cancer, but discovered a small cell/neuroendocrine transformation. And this is why proper documentation of clinical history is so important to pathologists and laboratory professionals. In one of my earlier posts, I preached that cancer doesn’t discriminate; so why should we? Keeping an open mind is paramount to both succeeding in and enjoying the field of cytopathology. If it looks like a duck, and it walks like a duck, it might actually have transformed into a goose.

-Taryn Waraksa, MS, SCT(ASCP)^CM, CT(IAC), has worked as a cytotechnologist at Fox Chase Cancer Center, in Philadelphia, Pennsylvania, since earning her master’s degree from Thomas Jefferson University in 2014. She is an ASCP board-certified Specialist in Cytotechnology with an additional certification by the International Academy of Cytology (IAC). She is also a 2020 ASCP 40 Under Forty Honoree.

The Great Mimicker

I’ve witnessed that radiologists are often hesitant to perform a core biopsy on a spleen due to its vascularity, so when I attend spleen FNAs, I rarely push. Even when the oncology team requests both a core biopsy and FNA for a hematology workup, I will acquire as many passes as possible from an FNA to work up cytomorphology and flow cytometry before risking a core-induced hemorrhagic complication. When I was called to attend an ultrasound-guided spleen biopsy, I went in knowing two things: the patient has both splenic and brain lesions, and I was going to make the most of what I was given. When I arrived in ultrasound, the radiologist informed me that the patient had polycythemia vera (PV), which would explain the splenomegaly, but not the brain lesions. The patient, a 65 year old male, received the diagnosis in 2009 and was managed with phlebotomies for six years until a rising platelet and white blood cell count required an intervention of hydroxyurea. Within 18 months, the patient developed a PE and dizziness and began therapeutic anticoagulation. At the same time, the patient’s “metastatic lesions” were identified on imaging. The first state of business is finding out if his PV had progressed into myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). There was something… off… about this case though. It didn’t feel like a heme case (not that I prefer non-heme cases… well, okay, I’m a cytotech, so I kind of do). The brain lesions concerned me, and I didn’t know what to infer.

Let’s progress to the FNA. Here are the air-dried, Diff-Quik smears that changed everything.

Images 1-2: Splenic mass, fine needle asperation, DQ-stained smears.

What non-heme surprise is THIS?! Are these histiocytes? There’s no way, those nucleoli are aggressive! Look at the chromocenters! The variation in nuclear size! What epithelial beauty is this? Is it epithelial?! Is that a fibrovascular core? It can’t be sarcomatoid, could it? Twenty inner monologue questions later, “okay, it’s adequate,” I said to the radiologist. But wait… should I do it? Should I press for a core biopsy? The radiologist asked me if I needed anything else for the diagnosis. Perhaps she saw my puzzled expression, compelling her to tell me that she felt the imaging looked weird – she thought it wasn’t a heme case either. At least I’m not alone here. I took a deep breath, expecting the worst and hoping for the best, and I asked the radiologist to collect a core biopsy. She checked the ultrasound Doppler for excessive vascularity, and much to my surprise, she agreed to perform the core. After collecting more FNAs for my cell block and dropping the core biopsies off in surgical pathology, I showed the case to my attending pathologist. He also agreed that we don’t need to triage it for heme. He asked if the patient had any significant history other than PV, splenic lesions, and brain mets, and I told him nothing was reported in his chart. I checked the chart again for good measure while he was running through his differential diagnoses of lung, GI, prostate, etc., and saw the patient was scheduled to see dermatology later that week. I mentioned to that to my attending, and he suggested it could be a melanoma.

The following morning, I examined the pap-stained slide and began to second guess myself. Was I wrong? Could it be a heme case? Hodgkin’s wasn’t in the differential, and these cells look so much more aggressive than Reed-Sternberg cells. At least we have a core biopsy either way. We could run immunos on the cell block and save the cores for molecular. I screened the pap-stained slides a little longer, focusing on the macronucleoli, the owl-eye and eccentric nuclei, the poorly-differentiated nature of this… MELANOMA. YES! So, the cells might not contain any melanin pigment, but my attending’s inkling was exactly right. Waiting for my cell block to arrive, I listed melanoma as my primary diagnosis with a differential of lung or prostate cancer.

Images 3-4: Splenic mass, fine needle aspiration, Pap-stained smear.

The cell block confirmed my non-heme diagnosis and kept my differentials at bay. The attending pathologist ordered an immunohistochemistry profile of S100, HMB-45, and Melan A, as well as AE1/AE3. The first three immunostains (prior to our adoption of SOX-10) confirmed a diagnosis of metastatic malignant melanoma. Soon thereafter, the patient’s primary lesion was identified on his back, and he was treated with radiation and immunotherapy. Unfortunately, the metastases were not responding to the immunotherapy, and a few days after a clinical trial was offered, the patient passed away.

Images 5-8: Splenic mass, fine needle aspiration. 5 and 6, cell block, H&E; 7 and 8, Melan A+.

Melanoma is known as the great mimicker, especially in amelanotic form, and it should always be in the back of your mind as a differential diagnosis. Lack of melanin pigment and a large cherry red macronucleoli leads us to favor lung, prostate, or serous adenocarcinoma), renal cell carcinoma, hepatocellular carcinoma, Hodgkin’s lymphoma, or even an epithelioid sarcoma. This case highlights the need to remember that metastatic melanoma is always a possibility, even when you do not have a primary site or previous clinical history of the disease.

Cytology Case Study: Little Gland, Big Disease

A 59 year old female initially presented with DCIS, treated by mastectomy and 5 years of adjuvant tamoxifen at another institution. 4 years later, she presented to another hospital with an adrenal mass, uterine fibroids, and an ovarian cyst, where a biopsy and right-sided adrenalectomy confirmed a 10.5 centimeter adrenocortical neoplasm. Margins were close, but negative at <0.1 cm. Microscopically there were areas of necrosis, high nuclear grade, a diffuse growth pattern, and clear cells representing less than 25% of the tumor. A malignancy was favored, but lack of metastasis could not confirm the diagnosis. She presented to the cancer center with stage II adrenal cancer, T2N0M0 and mitotane-induced adrenal insufficiency. Multiple hepatic and pulmonary metastases were subsequently identified and treated with extensive surgery, including a VATS wedge resection, right nephrectomy, hepatic mobilization, lysis of adhesions, dissection of the adrenal vein and vena cava with repair, and resection of an ileal mass.

Palliative radiation therapy targeted the remaining lung nodules, and six cycles of chemotherapy were administered. A CT scan-guided fine need aspiration biopsy was obtained of a 4 centimeter retroperitoneal mass that was suspicious for recurrence on imaging, which cytopathology then confirmed. Taking into consideration the history, my additional differentials included renal cell carcinoma, hepatocellular carcinoma, and plasmacytoma, with metastatic breast cancer as the least likely differential.

Images 1-2. Retroperitoneal mass, right side, FNA-DQ stained smears.

Images 3-4. Retroperitoneal mass, right side, FNA-Pap stained smears.

Images 5-6, Retroperitoneal mass, right side, FNA-H&E cell block sections.

Palliative radiation therapy was then administered to the retroperitoneal and psoas masses, and microwave ablation targeted the segment 3 and segment 6 liver lesions, reducing pain and stabilizing growth, respectively. However, disease continued to slowly progress, so the oncology team sent the retroperitoneal metastasis tissue for molecular testing to assess for potential next lines of therapy. Testing revealed a variant of undetermined significance in MSH6, indeterminate tumor mutational burden, stable MSI, and negative for PDL1. When the case was brought to tumor board, the team recommended ongoing surveillance and palliative therapy (when needed) given the patient’s slowly progressing disease. Often thought of as a rare disease, I’ve examined a fair share of primary and metastatic adrenocortical carcinomas through working at a cancer center. These tiny triangular glands that sit on top of the kidneys have SO much power. Producing and regulating cortisol, aldosterone, and androgenic hormones, the adrenal cortex is an active outer layer. Whether hormonal or neoplastic, it truly is fascinating how a tiny gland could wreak so much large-scale havoc on the human body.

Mye-Lo-Mye: Cytology Case Study

I quickly transitioned from from learning at Jefferson to teaching at Jefferson less than 6 months after I graduated from the Cytotechnology program. Assuming this new role of teaching future cytotechnologists was a refreshing twist after continuously learning at work. I stood at the podium as an alumna in my previous classroom with a breadth of fresh material to work with, appreciate, and share. At the beginning of each lecture, I would check in on my students, ask them how their other classes were going, ask if they had any questions, and then, I would share an interesting case from my work week thus far. Aside from the weekly lecture on ancillary techniques, such as molecular and immuno-diagnostics, I assigned multiple activities such as journal club/conferences, discussions, and my personal favorite – a mock tumor board. Each student would take turns playing the role of the physician, radiologist, cytotechnologist, pathologist, and oncologist (surgical, medical, or radiation). For my first year of instruction, I had assigned the group their “tumor” of interest, but I quickly encouraged their creativity run rampant during subsequent years.

Despite working in a cancer center and being able to recognize some fairly obscure tumors with little experience, I did not realize how much I still had to learn, even as a part-time lecturer and full-time cytotechnologist. These tumor boards taught me so much more than I expected, and I am forever thankful for the experience of having such wonderfully bright students teach ME! For one very memorable tumor board, the students elected to present the diagnosis and treatment of a male patient with multiple myeloma. Yes, plasma cells! Plasma cell neoplasm, plasmacytoma, multiple myeloma. Awesome, let’s see what this group can do! The “physician” said the patient complained of widespread bone pain, malaise, and recurrent fevers and infections. The “radiologist” presented the images of osteolytic lesions throughout the skull and vertebrae, the latter of which core biopsies and FNAs were obtained. The “cytotechnologist” described a mix of plasmablastic cells, as well as mature and immature plasma cells, some with clock face chromatin and a perinuclear hof (which is my telltale feature that I now emphatically describe to everyone else). The “pathologist” bypassed flow cytometry and performed Kappa/Lambda light chain immunohistochemistry on the core biopsy, diagnosing the patient with multiple myeloma. Unfortunately, due to the extent of the patient’s disease, the “oncologist” and her team could not increase the life expectancy, and the student’s patient expired.

Now, whenever I have a plasma cell neoplasm or multiple myeloma case, I think back to my students and their mock tumor board and everything they taught me. I just recently attended an FNA on a 79-year-old male with a history of multiple myeloma who presented with a PET positive right facial mass and right cervical lymph nodes. The radiologist performed an ultrasound-guided FNA of a right peri-mandibular soft tissue mass, and it took everything in me to not tell the radiologist anything more than “adequate.” But when I saw those perinuclear hofs, I was elated to have a definitive diagnosis!

Images 1-2. Perimandibular Mass, Right, FNA-DQ-stained smears.

Later that afternoon, I couldn’t wait to screen my pap-stained slides. The clock face chromatin was so beautiful! My cell block the following morning highlighted the textbook perfect features diagnostic of a plasma cell neoplasm.

Images 3-4. Perimandibular Mass, right, FNA. Pap-stained smears.

Image 5. Perimandibular Mass, Right, FNA. H&# cell block section.

The attending pathologist ordered a routine myeloma immunocytochemistry panel, including CD138, kappa light chain, lambda light chain, CD20, CD45, and MUM1.

Immunocytochemical stains performed on the unstained paraffin sections showed the tumor to be positive for CD138, kappa light chain, and MUM1, focal equivocal staining for CD20, and negative staining for lambda and CD45. The case was signed out as a plasma cell neoplasm.

Images 6-8. Perimandibular Mass, right, FNA. Cell block section immunocytochemistry. 6, CD138; 7, MUM1; 8, kappa light chain.

The bone marrow core biopsy was sent for Cytogenetic Microarray Analysis and Next Generation Sequencing. The CMA results revealed gains of chromosomes 3, 5, 9, 11, 15, 19, and 21 and losses of chromosome segments 1p and 2p and 7 p in mixed states. Loss of 1p is associated with a poorer prognosis for multiple myeloma. Next gen sequencing identified a tumor mutation burden of 8.4Muts/Mb with mutations detected in the following genes: FAM46C, BRAF, KAT6A, TSC1, KRAS, FLT3, and NFKBIA.

Eye Spy 2.0

Now that you’ve seen some malignant ocular entities (both primary and metastatic), I’d like to share some (in my eyes) curveballs. Working in a cancer center, I see more cancer than I do benign processes. You can say I’m fine tuned to identifying malignant cells, and I find it difficult to rest assured that what I’m diagnosing truly is benign. When you find one malignant cell in a pleural fluid, changing the patient’s diagnosis from Stage II to Stage IV, that primed search for atypia is always on. With that said, not every specimen screened at a cancer center is malignant. We rule out malignancy and confirm benign processes as well. As for benign ocular FNAs, well… you have to be as certain calling benign as you do malignant because the process of acquiring an additional sample to confirm your diagnosis is just as involved and unpleasant as the first biopsy.

Here, I present six non-malignant eye FNA cytopreparations that had me searching for atypia longer than I expected.

Case 1. A 72 year old female with a history of breast carcinoma; She presented with a choroidal nevus, OD in 2014. The oncologist noted a slight increase in base and thickness six years after the initial evaluation. The clinical diagnosis is a choroidal nevus, rule out low-grade melanoma.

Images 1-2: Eye, Right, Choroid, Fine Needle Aspiration. Pap-stain.

Final Diagnosis: No malignant cells identified. A few benign-appearing melanocytes, consistent with nevus.

Note: Material is scant cellular and consists mainly of scattered retinal pigment epithelial cells and sensory cells. There are a few benign-appearing spindle-shaped cells with bland nuclei, consistent with nevus. However, the paucity of the sample precludes a definitive diagnosis. Recommend clinical correlation to exclude sampling error.

Case 2. A 21 month old male with a history of an iris stromal cyst, OS. Lesion is status post-FNA (twice), had regrowth, and aspirated for the third time. Previous FNAs showed no malignant cells.

Images 3-4: Eye, Left, Choroid, Fine Needle Aspiration. Pap-stain.

Final Diagnosis: No malignant cells identified. Rare pigment-laden macrophages, a few lymphocytes, and benign surface epithelial cells present. (Consistent with stromal cyst).

Case 3. A 65 year old female with a history of nevus, OD. Ocular oncology followed up and noted an increase in thickness from 2.76 to 3.00 mm. In light of family history of cutaneous melanoma, treatment is suggested. Clinical diagnosis: ciliary body melanoma.

Images 5-6: Eye, Right, Choroid, Fine Needle Aspiration. Pap-stain.

Final Diagnosis: Scant mildly atypical amelanotic spindle cells, consistent with nevus.

Note: Diagnostic material is very scant. There are a few benign-appearing single spindle cells and one cluster of cohesive spindle cells with no pigment. Prominent nucleoli are not seen. While the cytologic features in the context of clinical presentation is consistent with nevus, the paucity of the sample precludes a definitive diagnosis. There is no diagnostic evidence of malignant melanoma in this sample. Recommend clinical correlation to exclude sampling error.

Case 4. A 9 year old female with a history of retinoblastoma, OD; status post IAC (intra-arterial chemotherapy) x5, IVit melphalan x 4, and plaque radiotherapy. She recently developed vitreous hemorrhage (OD). Since the hemorrhage is obscuring the retinal view, vitrectomy is planned.

Image 7: Eye, Right, Vitreous, Fine Needle Aspiration. Pap-stain.

Final Diagnosis: No malignant cells identified. Lymphocytes and histiocytes present.

Case 5. An 11 year old female with vitreal retinoblastomas, OU; status post CRD therapy x6; plaque I-125, EBRT, proton beam; IVit Metphalan x2, and PPV (pars plana vitrectomy), OS. She now presents with dense vitreous hemorrhage blocking view since 2019.

Images 8-9: Eye, Left, Vitreous, Fine Needle Aspiration. Pap-stain.

Final Diagnosis: No malignant cells identified. Proteinaceous material and scattered small lymphocytes present.

Case 6. A 52 year old female with no cancer history. In 2019, she presented with pain, floaters, decreased visual acuity, and photophobia, OS. She was treated with antibiotic drops and steroids. In 2020, she was noted to have panuveitis with yellow iris nodules. FNA showed necrotic cells inadequate for diagnosis, as well as a negative culture and PCR for HSV, toxoplasmosis, CMV, and VZV. Clinical diagnosis: suspicious for iris lymphoma, OS.

Images 10-11: Eye, Left, Anterior Chamber, Fine Needle Aspiration. Pap-stain.

Final Diagnosis: Mixed inflammatory cells, favor an inflammatory process.

Note: There are neutrophils, lymphocytes, and scattered histiocytes in a background of numerous fragments of an amorphous substance. The cellularity is inadequate for flow cytometric analysis. We performed immunocytochemical stains on cytospin preparations. The lymphocytes are predominantly T-cells showing positive staining for CD45 and CD3 and negative for CD20. There is no diagnostic evidence of malignant lymphoma in this sample. The amorphous substance may represent lens fragments, in which case the possibility of lens-induced uveitis should be considered in the differential diagnosis. Recommend clinical correlation.

As you can tell, benign processes are complicated and require thorough explanations in our pathologic diagnoses, especially when they differ from the clinical impression. The majority of benign ocular FNAs are paucicellular, and we make the most of what we have through optimal preservation and preparation of cellular material. And don’t forget-not everything is cancer. Cyst contents, proteinaceous debris, and inflammatory cells make up a share of cases we see, and it’s okay to diagnosis them as benign. Just keep an eye out.

Eye Spy

In a previous post, I mentioned how uncontrolled cell division can occur in any cell type that has the capacity to proliferate, resulting in a neoplasm. Malignancies don’t discriminate – whether the malignant cell is identified within the skin, bladder, breast, bone, muscle, or brain – cancer is cancer. Fortunately, there are many specialists within various disciplines that can identify precancerous changes and other diagnostic abnormalities. Many patients in our head & neck clinic were referred by their dentist who identified a white patch on their tongue, a lump, or a sore that bleeds easily. Similarly, ophthalmologists can recognize ocular lesions during a routine eye exam, and I’m here to share some of those interesting ocular FNA cases. The idea of sticking a needle in your eye is perhaps one of the least pleasant thoughts a person can have, however, these FNAs are crucial for cytopathologists to analyze the cells to confirm a diagnosis.

Depending on the area of the eye sampled and the nature of the lesion, eye FNAs can yield very limited material. Optimal preservation and cytopreparation of ocular samples is imperative. At times, the sample may yield less than 50 cells, from which a diagnosis is expected to be made. Patient history and clinical impression are also crucial to properly triage the FNA. For suspected lymphomas, a portion of the sample should be sent to flow cytometry. For presumed melanomas and metastatic disease, extra preparations should be prepped for immunohistochemistry analysis. In contrast, a clinical impression of a stromal cyst is important to know as these FNAs are likely to be virtually acellular albeit rare cyst contents. The following four cases are presented with their histories and clinical impressions, supplemented by ancillary material.

Case 1. 58 year old male with a history of papillary thyroid carcinoma (2016) and renal cell carcinoma (2018). He presented with periorbital pain and a choroidal mass, OS.

Images 1-3: Eye, Left, Choroid, Fine Needle Aspiration. 1. Pap-stain; 2. vimentin +; 3. AE1/AE3 +.

Final Diagnosis: Positive for malignant cells, consistent with metastatic renal cell carcinoma.

Case 2. 58 year old female with a history of breast cancer. She presented with retinal detachment and nonpigmented nodules, OS.

Images 4-6: Eye, Left, Choroid, Fine Needle Aspiration. 4. Pap-stain; 5. GATA-3 +; 6. AE1/AE3 +.

Final Diagnosis: Positive for malignant cells, consistent with metastatic mammary carcinoma.

Case 3. 80 year old male with a history of lung adenocarcinoma (2012), pituitary adenoma (2013), and liver carcinoid (2019). He presented with a choroidal lesion, OS.

Images 7-10: Eye, Left, Choroid, Fine Needle Aspiration. 7. Pap-stain; 8. chromogranin +; 9. synaptophysin +; 10. TTF-1 +.

Final Diagnosis: Positive for malignant cells, metastatic neuroendocrine neoplasm (favor carcinoid tumor).

Case 4. 13 year old male with no cancer history. He presented with a choroidal lesion and retinal detachment, OD. Clinically suspicious for choroidal melanoma.

Images 11-14: Eye, Right, Choroid, Fine Needle Aspiration. 11. Pap-stain; 12. H&E; 13. HMB-45 +; 14. Melan A+.

Final Diagnosis: Positive for malignant cells, malignant melanoma (spindle B cell type).

Treatment of eye tumors can range from topical chemotherapies or excision for lesions on the surface of the eye, whereas intraocular tumors can be treated by brachytherapy or evisceration (removing intraocular contents and leaving the scleral shell) or enucleation (complete removal of both the intraocular contents and the scleral shell). While prosthetics are available for the latter therapies, an accurate cytopathology diagnosis is vital to guide treatment in the field of ocular oncology.

Well, that’s all that EYE have for you today. Stay tuned for next month’s cytology case study!

Lead Like No One is Watching

Even though I readily share and celebrate my accolades with family and friends, I have generally been quiet with my coworkers regarding career moves. When I passed the ASCP Specialist in Cytotechnology BOC exam three years into my career as a cytotechnologist, I only shared the news with my supervisor, cytopathology director, and a few other pathologists. After dabbling in budget and supply purchasing and compiling monthly and annual QA statistics, I completed ASCP’s certificate program from Lab Management University in 2018. The following year, I traveled to Puerto Rico for the American Society for Cytotechnology (ASCT) conference and sat for the International Academy of Cytology (IAC) Comprehensive Examination. Six weeks after the exam, I received word that I passed, and again, I immediately shared the exciting news with my supervisor and cytopathology director. No one else at work had a clue until a year later when they noticed extra initials behind my sign-out signature. Then, the ASCP 40 Under Forty application and eight weeks of waiting came and went this past summer and once again, I elatedly celebrated with my superiors. I have always moved in silence amongst my peers to maintain an inclusive and docile/same-level environment. While some might be supportive, not everyone actively encourages growth. Furthermore, not everyone wants an all-you-can-eat buffet on their work plate, and many lab professionals are happy with a less stressful, entry-level competency kind of routine. And that is perfectly A-OK too! Regardless, I am who I am, and for the lab professional who loves continuing education and learning new techniques and advancements across the field of health care, I wondered what career moves I would make in 2021. What goals should I set out to achieve? What is my next step?

There it is. A doctoral program. 100% Online and meant for the full-time working professional. I have officially embarked on my eight-semester-long journey to earning a Doctorate of Health Science (DHSc) with a concentration of Organizational Excellence in Healthcare. Rather than a traditional PhD which prepares scholars for research-based careers in a very focused area, the DHSc is an applied doctorate focusing on healthcare leadership in various disciplines. Now that I am halfway through my first semester, I can honestly say this is one of the best decisions I have ever made. Learning about applied leadership theory in healthcare and how to effectively, efficiently, and efficaciously lead in a complex healthcare landscape has been so intellectually stimulating thus far. Most recently, my classmates and I engaged in a discussion emphasizing how today’s leaders must stay relevant in their dynamic fields, and we shared our required competencies (i.e., the knowledge, skills, and abilities) for leading people and managing resources for both today and tomorrow (Ledlow & Stephens, 2018). A recurrent theme we uncovered is the necessity for continuing education – whether it be formal or informal. Staying relevant requires healthcare leaders to read, research, and teach. As cytotechnologists, we have existing continuing education programs in place, such as ASCP’s Credential Maintenance Program, recommending certificants to participate in and record credits to renew their certifications. We have Interlaboratory Comparison Programs through the College of American Pathologists (CAP) that feature ancillary studies as a diagnostic companion to cytology slides. We watch cytoteleconferences provided by the American Society of Cytopathology (ASC). We are encouraged to attend our affiliated societies’ national conferences to collaborate interprofessionally. With all that is available, however, we still need to do more than just claim continuing education credits.

We need to stay abreast on how our field of laboratory medicine is changing and how we can accommodate those changes and adapt to those changes. We need inspiration and motivation throughout the organizational hierarchy. We need passion and commitment from all levels and all disciplines. We need transformational, flexible, and culturally competent leaders to serve as mentors for the next generation of leaders. We need leaders who continuously self-reflect and improve as they build diverse, yet cohesive teams that thrive on generating positive outcomes for the organization. To the current leaders, leaders-in-training, and the followers with potential – we must get better, we must take more initiative, we must aspire to learn more than just the “what” or the “how,” but most importantly the “why.” For the upcoming year and beyond, I challenge you to continuously learn more about your field of laboratory medicine and its impact on society. Ask why the pap guidelines have changed. Ask about the advantages of robotic bronchoscopy. Ask what molecular tests are available and which are currently in development. Ask what we can do to reduce the burden of disease in our community! Refrain from saying, “I don’t know” and respond with, “I’ll find out.” Become an expert in your field by understanding the interdependency of laboratory disciplines and beyond, and strive to actively network with each other. For those who want more, please do more! Pursue more! There is no ceiling on your potential, and there are no limits to your growth.

So sayonara to 2020, and hello to 2021! New year, new me? No. New year, improved me. And hopefully an improved you!

Image 1. “Be a Star!” (Thyroid, FNA – DQ-stained smear. Dx: Papillary Thyroid Carcinoma)

References

1. Ledlow, G.R. & Stephens, J.H. (2018). Leadership for health professionals: Theory, skills, and applications (3rd ed.) Jones & Bartlett Learning.

The Rogue Anastomosis: Cytology Case Study

There are well over a hundred different cells types in the human body, and all those that have the ability to proliferate physiologically have the potential to succumb to uncontrolled cell division and thus generate a neoplasm. The tumors we most frequently encounter, like epithelial or hematologic disorders, are due to the higher proliferative rate of those cell types and the increased likelihood of an aberration or something going awry, i.e. mutations.² Though we do come across many sarcomas and other mesenchymal tumors, this case study features a tumor derived from a cell type and structure that is rarely featured in cytology texts (an assumption, as I couldn’t find any information in the available prints within my department).

A 54 year old male patient presented to gastroenterology for severe cholecystitis. After undergoing a laparoscopic cholecystectomy, the pain subsided, but the patient was encouraged to follow up with a colonoscopy and upper endoscopy (EGD) due to his age. On the EGD, the gastroenterologist identified Barrett’s esophagus as well as a small, oval intramural lesion in the greater curvature of the gastric antrum, measuring 1.6 centimeters. The gastroenterologist was sharing the patient’s history with me when he described the endoscopic ultrasound findings of a well-defined hypoechoic and heterogenous lesion appearing to originate from the muscularis propria. His differential diagnoses based on imaging included a GIST, leiomyoma, or glomus tumor. The gastroenterologist did mention that the likelihood of this being a GIST or leiomyoma was very low. Despite lack of vascular structures visualized on Doppler imaging, the needle passes which I received to make air-dried Diff-Quik-stained smears were exceptionally bloody both grossly and microscopically.

I called my pathologist on cytology service for the day, informed him of the history presented to me by the gastroenterologist, and upon seeing the “rare atypical cells” through our telepathology platform, I hear him say, “a glomus tumor? Hmm, yes, it could be a glomus tumor.”
You know that feeling when you’ve asked someone to repeat themselves three times and you still didn’t comprehend them, so out of courtesy, you pretend to know what they said and express understanding? Yet internally you are confused beyond repair?

I repeated back to the gastroenterologist, “he said it could be a glomus tumor!”
Here comes the inner dialogue – what on earth is a glomus tumor? Why am I trying so hard to not look like an idiot right now? It’s okay to not know things, especially rare tumors that you’ve never come across. I have no idea what this tumor is, where it originates, what it consists of, this looks like a cohesive neuroendocrine tumor to me or even a basaloid squamous cell carcinoma. Obviously, it’s representative of the lesion, but I have no idea what a glomus (should I be pronouncing it with a long “o” or a short “o”?) is.

Images 1-2. Distal Gastric Antrum, Submucosa, FNA – DQ-stained smears.

After screening the Pap-stained smears and H&E Cell Block sections the next morning, the cells still had cuboidal cells with features similar to a neuroendocrine tumor to me. The best I could call it was a neoplasm with neuroendocrine features before leaving the case with the pathologist on service to order immunostains.

Images 3-5. Distal Gastric Antrum, Submucosa, FNA – 3-4: Pap-stained smears; 5: H&E cell block section

IHC returned that afternoon, showing the neoplastic cells to be positive for SMA, focal weakly positive for synaptophysin, and negative for PanCK, CD34, desmin, chromogranin, CD45, DOG-1, HMB-45, and S-100 protein. Between the immunostains and the morphology findings, the case was signed out as a glomus tumor. Additional immunostains were performed showing the tumor cells are positive for vimentin and have a Ki-67 proliferation index of only 1%. When the tumor was resected two months after the initial FNA, pathology reported the findings as a 1.0 centimeter glomus tumor that was completely excised.

Images 6-7. Distal Gastric Antrum, Submucosa, Resection – 6, H&E section 100X; 7, H&E section 400X.

This tumor arises from the glomus body, which is a normal arteriovenous shunt that aids in regulation of temperature and blood flow in the body. Surrounded by smooth muscle tissue, the glomus body contracts and relaxes, closing and opening the shunt between the efferent venules and the afferent arteriole to pull blood flow away from the periphery and back into the body’s core or to allow heat dissipation. Glomus tumors are most often found in the dermis of the fingertips and toes, especially under nail beds due to the pain and cold sensitivity from exposure to cold.^1,5Glomus bodies are also found in the stomach as a thermoregulator (think cold food/liquids entering the digestive system), and account for 1% of mesenchymal gastric tumors.⁴ Most glomus tumors are benign and rarely undergo malignant transformation, and complete excision of these tumors typically provides immediate relief with little to no chance of recurrence.^1,3

References

Fazwi, R., Chandran, P. A., & Ahmad, T. S. (2011). Glomus Tumour: A Retrospective Review of 15 Years Experience in A Single Institution. Malays Orthop J., 5(3), 8-12. doi:10.5704/MOJ.1111.007
Holly, J. M. P., Zeng, L., & Perks, C. M. (2013). Epithelial cancers in the post-genomic era: should we reconsider our lifestyle? Cancer and Metastasis Reviews, 32(3–4), 673–705. https://doi.org/10.1007/s10555-013-9445-5
Nascimento, E. F. R., Fonte, F. P., Mendonça, R. L., Nonose, R., de Souza, C. A. F., & Martinez, C. A. R. (2011). Glomus Tumor of the Stomach: A Rare Cause of Upper Gastrointestinal Bleeding. Case Reports in Surgery, 2011, 1–5. https://doi.org/10.1155/2011/371082
Papadelis, A., Brooks, C. J., & Albaran, R. G. (2016). Gastric glomus tumor. Journal of Surgical Case Reports, 2016(11), rjw183. https://doi.org/10.1093/jscr/rjw183
Uddin, M. M., Biswas, S. K., Rahman, M. H., Karmakar, N. C., Rahman, M. M., Alam, S. A. U., & Mondal, A. R. (2017). Sub-ungual Glomus Tumor: Study of 20 Cases. Faridpur Medical College Journal, 12(2), 64–67. https://doi.org/10.3329/fmcj.v12i2.34230

Cytology Case Study: Strike a Chord

Every FNA ROSE attended where the patient is conscious and attentive can be tricky to navigate. You have to remain cognizant of your word choice, your demeanor, and the delivery of your adequacy statement to the clinician. The patient is already in a heightened state of awareness because he or she is about to be probed with a needle (or six!) for a test that is likely to rule out a benign or malignant process. I prefer to go into my biopsies with some sort of clinical picture and as many details as I can retain – is there a previous history of cancer? Where is the lesion located? Is it a single mass or are there multiple lesions? What does the radiologic imaging suggest? Are there any elevated serum tumor markers? I need to be able to walk the walk and talk the talk. However, there are rare instances when cytotechs are asked to rush down to an unscheduled add-on biopsy where we have yet to research the impression documented in the patient’s medical record. In those situations, I ask the clinician (typically an interventional radiologist) all the questions I can think of while still emulating some form of confidence to the patient.

I entered the procedure room and greeted the radiologist, radiology fellow, tech, nurse, and the patient, a 57-year-old male who was prone and alert on the table. I jotted down notes during the timeout and pulled the radiologist aside to ask, “does the patient have a history of cancer?” In this case, the answer was “they have a soft tissue tumor in the left gluteus, which is what we’re biopsying.” “Alright, let’s get those differentials rolling – sarcoma; after my hibernoma experience – a lipomatous tumor; or could it be a carcinoma (because yes, I’ve seen a lung adenocarcinoma metastasize to the gluteal muscle before)? Hmm… what else? What other mesenchymal tumors could originate here… or metastasize here?” My brainstorming balloon was popped by the radiologist asking if I was ready for the first needle pass. I replied, “Yes, of course!” I glance over at the patient and smile, trying to assure him AND myself that I’ll be able to give him a definitive answer to his puzzle.

Here’s what I visualized under the microscope after I stained the first air-dried smear in our Diff-Quik solutions.

Images 1-2. Left gluteal FNA, DQ-stained smears.

My inner monologue became: “Well, it’s not a sarcoma or a carcinoma. It doesn’t look malignant. Not quite a hibernoma. What is with that myxoid matrix? It’s not mucinous or serous, so… what is it…? It’s granular! Wait. Those nuclei. They’re so… what’s the word? It’s definitely representative of the lesion. Regardless, it’s adequate!” I turned away from my microscope to face the team – “The sample is adequate. May I have a few more passes for my cell block, and will you collect core biopsies, too? “Yes and yes,” the radiologist replied. I smiled again at the patient, and he mouthed, “thank you.” “Phew, mission accomplished,” I thought. “Now what the heck are those hallmark cells called mixed in with a majority of epithelioid cells arranged in chords?”

I climb the stairs up to the lab and do a quick Google search. “DUH! Physaliphorous cells!” These cells have a distinct feature where the nucleus is centrally located but is also scalloped by cytoplasmic vacuoles. There weren’t as many physaliphorous (physaliferous) cells as I had hoped to appreciate. Some of the cells looked lipoblastic in nature with larger vacuoles displacing the nuclei to the periphery, almost signet ring in nature, many were cuboidal. But that was it… those cells! Now, imagine the scene in Finding Nemo where Nemo struggles to tell his classmates he lives in an anemone. That was my garbled attempt at pronouncing “physaliphorous” to the attending pathologist when sharing my interpretation. She looked at me like I was saying anything other than the word I was trying to reproduce. I cannot blame her; I still turn beet-red at the memory. But I was convinced that a chordoma was the tumor I presented to her.

After I processed my FNA, I examined the patient’s electronic health record to see if he had any previously biopsied neoplasms on file, and much to my surprise, the patient was diagnosed with a primary chordoma of the sacrum and treated with en bloc resection and radiation in 2013. Mutation analysis was performed on the resection of this chordoma, which exhibited a homozygous loss of CDK2NA (p16). The patient had one recurrence at an outside facility in 2015 and transferred his care to our institution for follow-up. Now, the patient presented with this gluteal metastasis and soon thereafter, a paraspinal metastasis. As the patient’s chordoma did not completely respond to radiation, the clinical care team turned to the tyrosine kinase inhibitor, Gleevec, which was discontinued due to disease progression. The patient’s regimen then went on to include sunitinib, which was also discontinued due to disease progression, palbociclib, then nivolumab, followed by radiation to the thoracic spine, sorafenib, and now is on a clinical trial for patients with advanced refractory cancers.

When I turned in my Diff-Quik & Pap-stained slides and the cell block H&E sections with a diagnosis of chordoma the next day, the attending cytopathologist paged through one of our cytology texts to a tidbit on chordomas before signing out the case. She reviewed the section with me. Other than the unique physaliphorous cells, it turns out a diagnosis of chordoma is fairly rare, as it is the only malignancy derived from the notochord, typically occurring at either end of the axial skeleton.¹ Metastasis of these tumors is also rare, so this case of widespread metastatic disease was even more intriguing to me.

Images 3-8. Left gluteal FNA . Images 3-5, Pap-stained smears; 6-8, H&E cell block sections.

References

Cibas, E. S., & Ducatman, B. S. (2009). Cytology: Diagnostic Principles and Clinical Correlates, Expert Consult – Online and Print (3rd ed.). Saunders.

It’s Gettin’ Hot in Here: Cytology Case Study

In my previous post here on Lablogatory, I discussed the diagnosis and comparison of two mediastinal fine needle aspiration (FNA) cases – thymoma and thymic carcinoma. I tooted my own horn of how I instantly recognized the tumors on Rapid On-Site Evaluation (ROSE), as the characteristics were exactly how I remembered them from my cytology knowledge bank formulated in grad school. Here’s a case that completely threw me off my game. I had never seen this type of tumor nor heard of it, at least not to my memory, but that’s the beauty of lab medicine—we’re continuously learning.

A 43 year old female with hypertension and no cancer history presented to a vascular surgery clinic for treatment of varicose veins, and an ultrasound was performed, noting a mass in the left inguinal region. The patient subsequently had an MRI, which demonstrated a predominantly fatty mass in that area with enhancement and probable necrosis within the lesion. The differential diagnosis determined by imaging was fat necrosis versus liposarcoma. With this risk of malignancy, the patient came to our institution for biopsy and further guidance. The ultrasound department visualized the left inguinal mass of mixed echogenicity, measuring 3 centimeters with a focal area of central necrosis.

After receiving two FNA passes of the patient’s left inguinal mass from the radiologist, I made mirror-image smears of the samples, air-drying one slide for Rapid On-Site Evaluation (ROSE), fixing the other in 95% Ethanol, and rinsing the needles in Hanks Balanced Salt Solution to later make a FFPE-Cell Block.

Image 1. Left inguinal FNA, DQ-stained smear.

Image 2. *Left inguinal FNA*, Pap stained smear.

Image 3. *Left inguinal FNA*. H&E cell block section.

I remember my differentials – Lipomatous tumor of unknown etiology versus clear cell renal cell carcinoma versus adrenal cortical carcinoma. I knew it was a neoplasm of sorts and that we had adequate material for a diagnosis. But I could not make a definitive diagnosis, and it mind-boggled me. That’s when my cytopathology director reviewed the case with me, and I went straight to the cytology encyclopedias.

The FNA specimen was signed out as a “Benign-appearing adipose tissue neoplasm, consistent with hibernoma.

Image 4. Left inguinal core biopsy, H&E section 100X.

Image 5. Left inguinal core biopsy, H&E section 400x.

Hibernoma was also diagnosed on the concurrent core biopsy specimen by the surgical pathologist on service.

Hibernomas are rare brown fat tumors that typically develop where brown fat is normally distributed throughout the body, such as the upper back, thigh, and retroperitoneum.² Brown fat, or brown adipose tissue is responsible for non-shivering, mitochondria-rich thermogenesis.³ From the cytology images, one can appreciate the small, eccentric nuclei and capillaries, featuring three cell types: mature adipocytes (think lipoma), lipoblast-like cells (think liposarcoma), and hibernoma cells, which appear to be highly, but uniformly vacuolated adipocytes with granular cytoplasm.

Two months after the initial biopsy, the patient underwent a radical resection of her left thigh hibernoma en bloc with a portion of the iliopsoas muscle and femoral nerve neurolysis. The intraoperative findings showed a 5.2 centimeter well-circumscribed mass directly beneath the femoral vessels, beginning at the common femoral artery and extending to the level of bifurcation of the superficial femoral artery and profunda. The mass was adherent to the posterior wall of the vessel, but fortunately did not involve the adventitial layer. The mass, however, was more adherent to the pectineus muscle and inseparable from the middle portion of the iliopsoas muscle. The mass was also adherent to the hip, and in order to clear the mass from that space, an arthrotomy was made.

Image 6. Left inguinal resection, H&E section 100 x.

Image 7. Left inguinal mass resection, H&E section 400x.

The surgical pathologist signed out the case as follows:

– Hibernoma with focal myxoid changes, 5.3. cm. The inked margins showed no tumor.

In the middle of the hibernoma, there was a nodular myxoid lesion with spindle cells. Due to a question of liposarcoma, cytogenomic microarray analysis (CMA) was performed which was negative for genomic imbalances. Immunostain performed on a frozen section of tissue showed that the atypical cells were positive for Desmin, confirming that they are skeletal muscle.

If this case was diagnosed as a liposarcoma rather than hibernoma, one would see atypical lipoblasts with more prominent capillaries, like a well-differentiated liposarcoma. Depending on the type of liposarcoma, one might also identify a myxoid stroma or round cells.²

Hibernomas are a unique kind of tumor where the consensus on how to manage them remains split – some favor observation, while others suggest surgical intervention. From the literature, there are no reports to suggest metastasis or malignant degeneration/transformation, but many do favor a resection if feasible.¹

References

AlQattan, A. S., Al Abdrabalnabi, A. A., Al Duhileb, M. A., Ewies, T., Mashhour, M., & Abbas, A. (2020). A Diagnostic Dilemma of a Subcutaneous Hibernoma: Case Report. American Journal of Case Reports, 21, 1–5. https://doi.org/10.12659/ajcr.921447
Cibas, E. S., & Ducatman, B. S. (2009). Cytology: Diagnostic Principles and Clinical Correlates, Expert Consult – Online and Print (3rd ed.). Saunders.
Cypress, A., & Khan, C. (2010). The Role and Importance of Brown Adipose Tissue in Energy Homeostasis. Curr Opin Pediatr, 22(4), 478–484. https://doi.org/10.1097/MOP.0b013e32833a8d6e

Taryn Waraksa, MS, SCT(ASCP)^CM, CT(IAC), has worked as a cytotechnologist at Fox Chase Cancer Center, in Philadelphia, Pennsylvania, since earning her master’s degree from Thomas Jefferson University in 2014. She is an ASCP board-certified Specialist in Cytotechnology with an additional certification by the International Academy of Cytology (IAC). She is also a 2020 ASCP 40 Under Forty Honoree.