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Early detection is a major goal for reducing mortality of human cancer. However, non-invasive detection of early stage tumors has remained a challenge. We have developed an approach called Targeted Error Correction Sequencing (TEC-Seq) for ultra-sensitive analyses of circulating cell-free tumor DNA (ctDNA). This methodology involves in-solution targeted capture of multiple regions of the genome and deep sequencing (~30,000x) of cell-free DNA fragments. Laboratory and bioinformatic methods were optimized to enrich for rare ctDNA molecules and to reduce potential amplification, sequencing, and contamination errors. We have used this approach to examine 58 cancer related genes, and demonstrated a limit of detection of mutant to wild-type DNA of 0.05% and a specificity >99.999% across targeted regions of interest. We applied this method to analyze plasma from healthy individuals as well as over 200 individuals with breast, lung, colorectal and ovarian cancers. Analysis of plasma from 44 healthy individuals revealed no tumor-related somatic mutations and identified alterations in genes related to myelodysplasia in a subset of cases. Among patients with cancer, we detected measurable ctDNA in 56%, 71%, 57%, and 56% of patients with early stage (I and II) breast, colorectal, lung and ovarian cancer. Over three quarters of patients with late stage (III and IV) disease had detectable ctDNA among all cases analyzed. Analyses of mutations in the circulation revealed a high concordance with alterations in the independently analyzed tumors of these patients. These analyses provide a widely applicable, ultra-sensitive, and non-invasive method for detection of ctDNA, and have important implications for detection of early stage disease and management of patients with cancer. Citation Format: Jillian A. Phallen, Mark Sausen, Vilmos Adleff, Alessandro Leal, Jacob Fiksel, Carolyn Hruban, Savannah Speir, Eniko Papp, Valsamo Anagnostou, Mai-Britt W. Orntoft, Thomas Reinert, Brian D. Woodward, Derek Murphy, Sonya Parpart-Li, David Riley, Monica Nesselbush, Naomi Sengamalay, Andrew Georgiadis, Rob Scharpf, Qing K. Li, Sian Jones, Samuel Angiuoli, Joost Huiskens, Cornelis Punt, Nicole van Grieken, Remond Fijneman, Gerrit Meijer, Hatim Husain, Luis Diaz, Torben Ørntoft, Hans J. Nielsen, Claus L. Anderson, Victor E. Velculescu. Detection of circulating tumor DNA in early stage cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr LB-246. doi:10.1158/1538-7445.AM2017-LB-246

This chapter is focused on the discussion and review of cytomorphology of benign and malignant lesions in the serous fluid, including pericardial and pleural effusions and peritoneal fluid (ascites). Infectious diseases, lymphomas, mesothelioma and other malignant lesions can be found in serous fluids. The most common malignant lesions are metastatic carcinomas, such as metastatic lung and breast carcinomas in pleural effusions, as well as metastatic gastrointestinal and/or gynecological carcinomas in peritoneal fluids. The diagnostic and differential diagnostic key features of benign and malignant lesions are listed and reviewed. In addition, the utility of immunohistochemical markers in the differential diagnosis is also discussed.

This chapter is focused on the discussion and review of cytomorphological features of benign and malignant respiratory lesions. The respiratory system can be divided into upper and lower tract, thus, the variety of sampling and preparation methods are also reviewed, since the cytomorphology of the lesion may reveal differently depending on the sampling and preparation techniques. In addition, the critical information regarding molecular tests of lung carcinomas are also reviewed.

This chapter is focused on the discussion and review of benign and malignant liver lesions. The differential diagnosis of a liver mass is broad, including both benign and malignant tumor. The liver is also frequently involved by the metastasis in cancer patients; therefore, the FNA cytology plays a critical role in the work up of liver masses. Although most liver lesions can be accurately diagnosed by FNA, the limitation of the FNA cytology should also be considered. For example, the diagnosis of focal nodular hyperplasia (FNH), hepatic adenoma, and regenerative nodule may not be made based on cytomorphology. Nevertheless, the false-positive diagnosis is rare in daily practice.

The fine needle aspiration (FNA) cytology, either under CT- (computed tomography) or ultrasound-guidance, is a commonly used approach to obtain samples from renal and adrenal lesions. This chapter is focused on the discussion and review of cytomorphology of FNA specimens of benign and malignant diseases of the kidney and adrenal gland. Although the differential diagnosis of a kidney mass is broad, including both primary and metastatic tumors, the majority of kidney masses are primary kidney tumors. Whereas, in adrenal masses, the majority of tumors are metastatic tumors rather than primary adrenal tumors. The limitations of the FNA cytology in the diagnosis of renal and adrenal lesions are also discussed in the chapter. For example, the cytological differentiation of an oncocytoma from a chromophobe renal cell carcinoma may be difficult due to overlap cytomorphology. Nevertheless, the most renal and adrenal lesions can be accurately diagnosed by FNA cytology.

In the gastrointestinal (GI) tract, the most commonly used techniques to obtain samples are endoscopic mucosal brushing, the fine needle aspiration (FAN), and forceps biopsy, however, the forceps biopsy is often considered as a surgical biopsy specimen. This chapter is focused on the discussion and review of cytomorphology of brushing and FNA specimens of benign and malignant diseases in upper and lower GI tract, and biliary duct. The GI cytology has also been used in the monitoring disease progression, such as in patients of Barrett’s esophagus and ulcerative colitis, since the technique of mucosal brushing may sample wider area than that of the biopsy. The differential diagnosis of a GI lesion is broad, including both benign and malignant diseases. The limitation of the GI cytology are also discussed in the differential diagnosis.

Patients with previously resected papillary thyroid carcinoma (PTC) are monitored for disease recurrence/metastasis by ultrasound surveillance and fine-needle aspiration (FNA) cytology. However, accurate diagnosis in lesions with cystic degeneration may be difficult due to scant cellularity. In the current study, the authors evaluated thyroglobulin in FNA (Tg-FNA) for detecting metastatic and/or recurrent PTC in patients with cystic neck lesions after thyroidectomy.The pathology records were retrospectively searched for patients with previously resected PTC and subsequent Tg-FNA on a cystic neck mass. Tg-FNA was measured in needle rinses using a Tg assay. The ultrasound findings, Tg-FNA concentrations, and cytological and follow-up histological diagnoses were correlated.A total of 21 FNA specimens of cystic lesions from 19 patients were identified. Of 7 cases with cytologic and subsequent histologic diagnoses of metastatic PTC, the median Tg-FNA level was 100,982 ng/mL. Of 8 cytologically benign cases, 7 cases had Tg-FNA levels 0.2 ng/mL, and 1 aberrant case demonstrated elevated Tg-FNA of 1000 ng/mL. For 6 cytologically equivocal cases, including 3 classified as atypical/suspicious for carcinoma, 2 classified as insufficient/acellular debris, and 1 classified as spindle cell neoplasm, 4 patients demonstrated markedly elevated Tg-FNA levels (150 ng/mL) with subsequent surgical confirmation of metastatic PTC, whereas 2 patients had Tg-FNA levels of 0.2 ng/mL with negative follow-up. Using a cutoff value of 0.2 ng/mL, Tg-FNA demonstrated a sensitivity of 100% and specificity of 87.5%.Tg-FNA is a useful ancillary test that improves the detection of cystic PTC metastases. Particularly in cytologically nondiagnostic cases, the measurement of Tg-FNA helps to distinguish benign from malignant cystic lesions.

Hydroquinone (HQ), catechol, and phenol exist in microgram quantities in cigarette tar and represent the predominant form of human exposure to benzene. Exposure of human T lymphoblasts (HTL) in vitro to 50 μ m HQ or 50 μ m catechol decreased IL-2-dependent DNA synthesis and cell proliferation by >90% with no effect on cell viability. Phenol had no effect on HTL proliferation at concentrations up to 1 m m . The addition of HQ or catechol to proliferating HTL blocked 3 H-TdR uptake by >90% within 2 hr without significantly affecting 3 H-UR uptake, suggesting that both compounds inhibit a rate-limiting step in DNA synthesis. However, the effects of HQ and catechol appear to involve different mechanisms. Ferric chloride (FeCl 3 ) reversed the inhibitory effect of catechol, but not HQ, corresponding with the known ability of catechol to chelate iron. HQ, but not catechol, caused a decrease in transferrin receptor (TfR, CD71) expression, comparable to the level observed in IL-2-starved cells. HQ also inhibited DNA synthesis in cultures of transformed Jurkat T lymphocytes, primary and transformed fibroblasts, and mink lung epithelial cells, indicating that its antiproliferative effect was not restricted to IL-2 mediated proliferation. However, DNA synthesis by primary lymphocytes was more sensitive to HQ (IC50 = 6 μ m ) than that of the transformed Jurkat T cell line (IC50 = 37 μ m ) or primary human fibroblasts (IC50 = 45 μ m ), suggesting that normal lymphocytes may be particularly sensitive to HQ. The effects of HQ and catechol on DNA synthesis could be partially reversed by a combination of adenosine deoxyribose and guanosine deoxyribose, suggesting that both compounds may inhibit ribonucleotide reductase.

With increased use of the ThinPrep method for nongynecologic specimens, cell blocks are more commonly prepared by harvesting cells that are fixed in CytoLyt solution. The current study compared morphologic and immunocytochemical performance of effusion cell blocks prepared using CytoLyt-prefixed thrombin clot (CTC) with plasma thrombin clot (PT) and HistoGel (HG) preparation. The study included a total of 25 malignant or benign serous fluids. Three individual cell block materials were simultaneously prepared from each of the 25 effusion specimens using the CTC, PT, or HG method. H&E staining and immunostaining for pancytokeratin (pan-CK), carcinoembryonic antigen (CEA), epithelial membrane antigen (EMA), B72.3, HBME-1, estrogen receptor (ER), progesterone receptor (PR), CD45, CD20, and CD3 were then performed. The CTC preparation revealed compatible cellularity and good cellular details. In addition, CTC cell blocks revealed a similar percentage of cells with positive immunostaining along with the strongest intensity and the least background staining. The CTC method can be used reliably as an adjunct to other preparation techniques.

Ultrasound-guided fine-needle aspiration (US-FNA) cytology is a commonly used method in the surveillance of suspicious lymph nodes (LNs) in patients with papillary thyroid carcinoma (PTC). The measurement of thyroglobulin (Tg) levels in LNs during FNA has been suggested to improve the diagnosis. In the current study, the use of US-FNA-Tg in LNs that were suspicious for metastatic PTC was investigated.A total of 208 cases from the Johns Hopkins Hospital with both US-guided FNA cytology and US-FNA-Tg measurements were included; 60 cases had follow-up surgeries performed. Tg levels were correlated with cytological and histological diagnoses.Of 35 cases of cytologically diagnosed metastatic PTC, 34 were confirmed by surgery. The median US-FNA-Tg concentration was 4232.7 ng/mL, whereas in 112 benign LNs the median Tg concentration was 0.2 ng/mL (P .0001). Receiver operating characteristic analysis (area under the curve, 0.949) demonstrated a sensitivity of 97% and a specificity of 81% at the Tg detection limit (0.2 ng/mL), whereas cutoff values of 9.6 ng/mL to 100 ng/mL resulted in a sensitivity of 76% and a specificity of 98%. Of 15 cases with a cytological diagnosis of "suspicious for PTC," 9 cases had markedly elevated Tg levels detected on FNA. Seven of these 9 cases had follow-up surgeries confirming the diagnosis of PTC. Of 29 cases with a "nondiagnostic" cytology, 7 had markedly elevated Tg levels on FNA, with a median of 1305.5 ng/mL, and were confirmed to be metastatic PTC at surgery.US-FNA-Tg demonstrated a strong negative predictive value (93%-99%). It may be particularly useful for difficult cases. However, standardization of the sample collection is still needed to further improve the accuracy of the approach.

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

Several recent studies have suggested that EGFR and KRAS mutations may be different in primary and metastatic tumors. It is also not well studied whether or not conventional chemotherapy has any effect on EGFR or KRAS mutations. In this study, we compared EGFR and KRAS mutations in primary and unrelated metastatic lung adenocarcinomas from retrospectively collected clinical cases. We also examined the potential effect of chemotherapy on EGFR and KRAS mutations in these 2 groups based on available clinical information. Using Johns Hopkins Hospital archives, 379 lung adenocarcinomas with EGFR and KRAS mutational analyses were included. Mutational status was determined by sequencing exons 18 to 21 of EGFR and codons 12 and 13 of KRAS. Clinical information was correlated. The overall mutational rates in primary and metastatic tumors were comparable. In 213 primary tumors, there was no significant difference of EGFR and KRAS mutational rates in the prechemotherapy and postchemotherapy groups (P > .05), whereas in 166 metastatic tumors, EGFR and KRAS mutations were 12.8% and 36.1% in the prechemotherapy group and 27.3% and 18.2% in the postchemotherapy group (P < .05). Although our study is an unpaired study, it suggests that mutational status in metastatic tumors may need to be tested, especially if the patient had chemotherapy before the test. Additional studies are needed to further investigate the mechanism and clinical significance of the findings.

Objectives: Endorectal endoscopic ultrasound (ERUS) allows highly detailed assessment of the rectal wall layers and visualization of the extraluminal structures. Herein, we study the utility of ERUS fine-needle aspiration (FNA) to evaluate perirectal lesions. Study Design: Forty-nine ERUS-FNAs were retrieved from the cytopathology archives of The Johns Hopkins Hospital. The cytology slides, corresponding histology, immunohistochemistry when available, and clinical data were reviewed. Results: The aspirated material showed malignant (n = 24), benign (n = 19), atypical (n = 3), carcinoid tumor (n = 1), and nondiagnostic conditions (n = 2). The past medical history of 36 cases was significant for carcinomas. The primary site of the tumors included colorectal, urinary bladder, prostate, pancreas, gallbladder, ovary, and female lower genital tract. Statistical analysis for endoscopic ultrasonography FNA showed 87% sensitivity, 100% specificity, diagnostic accuracy of 90%, and a positive predictive value of 100% and a negative predictive value of 77%. Conclusion: ERUS-FNA can be utilized for: (1) accurate staging of colorectal adenocarcinomas by evaluation of nodal metastasis, depth of transmural tumor invasion and local tumor spread to perirectal fat, (2) prevention of aggressive surgical intervention in benign conditions, (3) providing diagnostic material for ancillary studies, and (4) evaluation of perirectal lesions with a more accurate method by combining imaging and histology.

Intrapancreatic accessory spleen is not an uncommon entity and usually located in the tail of the pancreas. Most of them are asymptomatic and incidental findings on radiologic study or at autopsy. On imaging study, it appears to be a well-defined, solitary, and hypervascular lesion; therefore, it may be confused with pancreatic neoplasms, such as neuroendocrine neoplasm, well-differentiated adenocarcinoma, solid pseudopapillary tumor, or metastatic tumor to the pancreas. As such, the diagnostic fine-needle aspiration biopsy of the lesion may be performed. Several case reports describing cytological features of the lesion have been published in recent years. Among them, the most commonly identified cytological findings are sheets of a heterogeneous population of lymphocytes and prominent traversing blood vessels. Herein, we report an unusual EUS-FNA case of intrapancreatic accessory spleen. In addition to above previously well-described cytological features, our case revealed many cells with fine granular chromatin and areas with pseudo rosette-like architecture, mimicking and engendering the differential diagnosis of pancreatic neuroendocrine tumors. Although cytological findings of our case are rare, they may extend our current knowledge and provide additional differential diagnostic information for this entity.

Papillary thyroid carcinoma (PTC) metastasis to the liver is a rare event and may cause diagnostic dilemmas. In this study, we have reviewed the cytological features of metastatic PTC to the liver, tested the BRAF V600E status of these lesions, and discussed potential diagnostic pitfalls. The pathological archives at the Johns Hopkins Hospital were searched for metastatic PTC. A total of 247 cases were identified; four cases were found to have metastases to the liver. Three of these cases were available for molecular testing to determine BRAF V600E status. All patients were female with ages ranging from 39- to 66-years old. Local lymph node involvement was found in all patients at the time of thyroidectomy. The average time of liver metastasis discovery following thyroidectomy was 16 years. The cytomorphology revealed predominantly microacini or two-dimensional clusters. Tumor cells were small-to-intermediate in size with oval nuclei, fine chromatin, nuclear grooves, rare intranuclear pseudoinclusions, and mitoses. In all cases, immunohistochemical stains for thyroglobulin and thyroid transcription factor 1 (TTF-1) were positive. All these tested cases were negative for the BRAF V600E mutation. The differential diagnosis includes adenocarcinoma and neuroendocrine neoplasms. The most important morphologic features for diagnosing PTC are the presence of pale finely granular chromatin, nuclear grooves, and intranuclear pseudoinclusions. A thorough review of the patient's clinical history and the use of appropriate IHC stains are essential in reaching an accurate diagnosis. Further molecular characterization is necessary to identify the changes most strongly associated with distant metastasis.

BACKGROUND:: Neuroendocrine (NE) neoplasms of the lung are a spectrum of tumors including typical carcinoid (TC), atypical carcinoid tumor (ACT), small cell lung carcinoma (SCLC), and large cell NE carcinoma (LCNEC). Given the overlapping features within these tumors, misclassification is a known risk, with significant treatment consequences. METHODS:: A search of the pathology archives from The Johns Hopkins Hospital yielded 390 cases of TC diagnosed over 20 years. Sixty-three cytology cases with corresponding surgical material were identified. The cytology specimens were comprised of 49 cases of lung fine-needle aspiriation specimens and 14 cases of lung brushings/washings. RESULTS:: Among 63 paired cases, 32 cases (51%) demonstrated concordant and 31 cases (49%) demonstrated discordant diagnoses. Among discordant cases, the most notable findings included overdiagnosis of TC as SCLC (4 cases; 6%), ACT (4 cases; 6%), and poorly differentiated carcinoma with NE features (5 cases; 8%) as well as misdiagnosis of other lesions as TC (4 cases; 6%) on cytology. CONCLUSIONS:: The significant morphologic factors for distinguishing low-grade TC from ACT, SCLC, or carcinoma remain the critical evaluation of nuclear features, chromatin patterns, and assessment of nucleoli. Nuclear molding and crowding are not discernible features because they may be found on smears with increased cellularity. Crush artifact can occur in both low-grade and high-grade NE neoplasms and may cause a misinterpretation of SCLC. Other artifacts resulting from delayed fixation or poor processing and sampling error are potential causes of incorrect interpretations. Ki-67 staining may be useful in difficult cases. Cancer (Cancer Cytopathol) 2010. © 2010 American Cancer Society.

In primary lung adenocarcinoma, EGFR and KRAS mutations are found in approximately 10% to 20% and 20% to 30%, respectively. Few studies have investigated these mutations in metastases. Patients with EGFR mutations have a 70% to 80% response rate to tyrosine-kinase inhibitors therapy and a longer progression-free survival rate in contrast to patients with KRAS mutations that are associated with virtually no response tyrosine-kinase inhibitors. In this study, we have investigated EGFR and KRAS mutations in metastatic lung adenocarcinoma. Using Johns Hopkins Hospital archives, 1966 lung adenocarcinomas were found from January 2007 to May 2010. A total of 60 metastatic adenocarcinomas (28 cytologic and 32 surgical cases) with EGFR and KRAS studies were identified. In addition, 18 cases of primary and matched metastases were also included. Exons 18 to 21 of EGFR and exon 2 of KRAS (codons 12 and 13) were sequenced. In our study, EGFR and KRAS mutations were found in 21.7% (13 of 60 cases) and 28.3% (17 of 60 cases), respectively, and occurred more often with advanced stage of primary tumors. KRAS mutations were associated with poor prognosis and occurred exclusively in smokers in comparison with EGFR mutation. Of 9 pairs, mutations were concordant in 77.8%; 1 pair displayed acquisition of KRAS mutation, whereas 1 pair showed loss of EGFR mutation in the corresponding metastasis. Our findings suggest that EGFR and KRAS status should be tested in metastasis regardless of known mutations of the primary tumor. Additional studies are needed to further investigate the mechanisms of discordances in metastatic tumors.

BACKGROUND: New developments in the treatment of lung cancer have necessitated the further histologic and cytologic subtyping of nonsmall cell lung carcinomas. Thyroid transcription factor-1 (TTF-1) long has served as the predominant marker for demonstrating lung origin. However, it is also expressed in a variety of other tumors, particularly neuroendocrine neoplasms and, to a much lesser degree, squamous cell carcinoma of the lung. Napsin-A, which is expressed in lung tissue, is a relatively new marker for lung adenocarcinoma. In this study, the authors examined the utility of napsin-A compared with TTF-1 in cytologic specimens of primary and metastatic, poorly differentiated lung adenocarcinomas. METHODS: The archives of the Department of Pathology at The Johns Hopkins Hospital were searched for cytologic cases of poorly differentiated lung adenocarcinoma that were histologically confirmed. In total, 75 patients (cases) along with 95 controls were included, each of whom had adequate cell block material for TTF-1 and napsin-A staining. Tissue microarrays of lung adenocarcinoma also were examined. RESULTS: TTF-1 and napsin-A were detected in 61 of 75 cases (81.3%) and in 49 of 75 cases (65.3%), respectively. The sensitivity and specificity of TTF-1 were 81% each; and napsin-A had a greater specificity of 96%, and sensitivity of 65%. Napsin-A was not detected in small cell carcinomas or in other carcinomas of nonlung origin except for renal cell carcinoma. CONCLUSIONS: Although TTF-1 had a higher sensitivity, napsin-A was useful as a surrogate marker when encountering a poorly differentiated lung adenocarcinoma or an unknown primary tumor, particularly in cytologic specimens and difficult cases. The current results indicate that the dual use of both markers may be necessary to improve diagnostic accuracy.

BACKGROUND: Endobronchial ultrasound (EBUS) is a relatively new modality that can be used to guide transbronchial needle aspiration (TBNA) of mediastinal and hilar lymph nodes and peripheral lung lesions. Few studies have investigated the cytological profile of EBUS-TBNA specimens. In this study, we have reviewed the cytological profile of 135 consecutive cases, including 71 lymph node cases, 4 lung cases, and 60 cases of both lymph node and lung sampling. Our study contains the largest number of cases in the evaluation of cytomorphology. METHODS: The cytological specimens were collected using an ultrasound bronchofibervideoscope with a 22-gauge needle and core biopsies were obtained with a 19-gauge needle. An experienced cytotechnologist performed an immediate on-site evaluation of adequacy. An immediate assessment was given to the clinician after each pass. In many patients, multiple sites were sampled. The average slides of each case were 9.9 (median of 12), with a range from 2 to 24. RESULTS: Of 131 cases of lymph node sampling, 45 cases (34.6%) were diagnosed as malignant, 73 cases (55.7%) as benign process, 5 cases (3.8%) as suspicious for malignancy, and 1 case (0.8%) as atypical cells. Of the 64 cases of lung lesion sampling, 21 cases (32.8%) were diagnosed as malignant, 35 cases (54.7%) as benign process, 1 case (1.5%) as suspicious for malignancy, and 4 cases (6.3%) as atypical cells. The lymph node nondiagnostic rate was 5.3%, whereas the nondiagnostic rate for lung lesions was 4.7%. Eighty-eight cases (65.2%, 88/135) had corresponding core biopsies (with a 19-gauge needle) or follow-up surgery. When histology was taken as the gold standard, the sensitivity, specificity, and positive and negative predictive values for EBUS-TBNA were 85.0%, 100%, and 100% and 89.7%, respectively. However, when both histology and clinical follow-up were considered together, the overall sensitivity and negative predictive values were increased to 94.7% (P < .05) and 96.6% (P < .05), respectively. CONCLUSIONS: This study shows that EBUS-TBNA is an accurate and sensitive method for diagnosing and staging lung cancer. The constant challenge that we as cytopathologists are now facing is how to improve our diagnostic ability and accuracy for lung cancer. We believe that this optimal goal can be achieved with the effective use of EBUS-TBNA sampling and collaboration with our clinical colleagues. Cancer (Cancer Cytopathol) 2009. © 2009 American Cancer Society.

Adrenal metastases usually occur in prostate cancer patients with widespread bone and visceral disease. Autopsy studies have shown that adrenal metastases may be found in up to 23% of these patients. However, the finding of an isolated adrenal metastasis without the involvement of other organs in a patient with prostate cancer is exceedingly rare. Thus, it may cause a diagnostic dilemma on FNA cytology. We report a patient with a history of prostate cancer, status post radiation, and hormonal therapy 4 years before, who presented with a new, single adrenal mass on abdominal imaging studies. The ultrasound-guided FNA cytology of the adrenal mass revealed cytomorphological features that were suggestive of a primary adrenal cortical neoplasm, but overlapped with those of a prostate metastasis. To our knowledge, FNA findings of metastatic prostate cancer simulating an adrenal cortical neoplasm have not been previously reported in the English literature. The purpose of our study is to discuss the differential diagnosis of these entities. The accurate diagnosis is important because of different prognosis and treatment implications for the various diseases. Diagn. Cytopathol. 2010. © 2009 Wiley-Liss, Inc.

Lymphadenomas (sebaceous and nonsebaceous types) of the salivary glands are extremely uncommon benign neoplasms. There are rare published reports of cytopathologic characteristics of "nonsebaceous lymphadenomas" of the parotid gland. We report herein, the case of an 80-year-old female who was evaluated at The Johns Hopkins Hospital for a 4.0 cm, nontender, mobile asymptomatic left parotid mass present for 3 months. An ultrasound-guided fine-needle aspiration revealed a uniform population of cohesive basaloid-type cells associated with scant myxoid stroma and was interpreted as "epithelioid neoplasm with basaloid features." Subsequently, a superficial parotidectomy was performed, which revealed a nonsebaceous type lymphadenoma. The rarity of this neoplasm and its superficial resemblance to more common salivary gland neoplasms may present diagnostic issues on FNA.

Renal medullary carcinoma (RMC) is a rare and aggressive malignant epithelial neoplasm of the kidney. It almost exclusively affects children and young adults with a sickle cell trait or sickle cell disease. The majority of RMC patients present with widely disseminated disease at the time of diagnosis. Herein, we report two cases of young African-American patients with history of sickle cell trait, hematuria and renal mass, who present with malignant right pleural effusions. The cytology of pleural effusion reveals predominantly clusters and individual tumor cells. The tumor cells show high nuclear to cytoplasmic (NC) ratios and large nuclei with nuclear pleomorphism, nuclear grooves, and prominent single or multiple nucleoli. The cytoplasm is dense with a vacuolated and two-tone appearance. Surgical specimens of renal mass and lymph node show features of RMC. Metastatic RMC to the serous cavity is rare and may present a diagnostic dilemma since it may mimic a poorly differentiated adenocarcinoma or other high-grade malignant neoplasms. RMC should be considered in the differential diagnosis in young patients with a renal mass, particularly in those with history of sickle cell trait or sickle cell disease.

Metastatic carcinomas to the thyroid are quite rare in daily cytology practice. However, when present they may produce a diagnostic dilemma, particularly when they share some morphologic similarities with primary thyroid lesions and when occurring in patients with occult malignant history. Herein, we report a case of metastatic gastric signet ring cell carcinoma to the thyroid. Our patient presented with an isolated right thyroid nodule, which was clinically considered to be a primary thyroid neoplasm. Fine-needle aspiration (FNA) cytology of the nodule revealed a cellular specimen with cohesive fragments and scattered individual neoplastic cells. The neoplastic cells had enlarged nuclei, fine chromatin, and inconspicuous nucleoli. Nuclear crowding, molding, and grooving were prominent. Intranuclear inclusion-like clearance was identified. Some tumor cells also had eccentric nuclei, creating a signet ring cell appearance. The colloid was scant. These cytological features may be seen in cases of papillary thyroid carcinoma or signet ring cell follicular adenoma; however, the presence of the signet ring cells is unusual in primary thyroid lesions and raises the possibility of a metastatic lesion to the thyroid. In our case, the tumor cells were positive for AE1/AE3, mucicarmine, and periodic acid-Schiff, but negative for thyroglobulin and thyroid transcription factor-1. The patient was also found to have a 3.7-cm mass in the distal esophagus/proximal stomach. Biopsy of this mass showed an invasive signet ring cell carcinoma. The purpose of our study is to discuss the cytological features and the differential diagnosis of this unusual thyroid FNA case. Diagn. Cytopathol. 2010;38:597–602. 2009 Wiley-Liss, Inc.

Retinoblastoma is a relatively rare malignant pediatric tumor accounting for approximately 3% of childhood cancers and 1% of all cancer deaths in children under 15 years of age. During the clinical course of the disease, a metastasis usually occurs within the first year of diagnosis and is seen in 2% of retinoblastoma patients. Metastases to the intracranial region are common and account for approximately 50% of the metastatic cases. Metastasis to the soft tissue is very rare. Herein, we report a case of metastatic retinoblastoma presenting as a left shoulder soft tissue mass in a 14-year-old female with a 14-year history of familial bilateral retinoblastoma status post radiation therapy. In our case, the FNA cytology shows some features of the small round blue cell tumor group with inconspicuous Flexner-Wintersteiner or Homer-Right rosette formation. The unusual clinical presentation and morphology give rise to a diagnostic dilemma, with the differential diagnosis centering on the small round blue cell tumors such as lymphoma, rhabdomyosarcoma, nephroblastoma (Wilms' tumor), Ewing's sarcoma/PNET, and desmoplastic small round cell tumor. It also prompts concern for the development of a second primary tumor. The purpose of our study is to discuss the FNA cytology of metastatic retinoblastoma, its differential diagnoses, and the utility of immunohistochemistry. An accurate diagnosis is imperative due to the differences in prognosis and treatment implications for the various diseases.

The book Prophylaxis and Early Detection of HPVRelated Neoplasia, edited by Herbert Pfister is now available. This book is the volume 28 of the Monographs in Virology series edited by H. W. Doerr. It is a hardcover 140 page text consisting of 13 chapters, 27 figures and 13 tables, devoted to the early detection and prevention of human papillomaviruses (HPV) infection and HPVassociated diseases. The book is mainly based on the continuously updated lectures of the HPV-Management Forum, established by the multidisciplinary working group of the Paul-EhrlichGesellschaft fur Chemotherapie in Germany. In past decades, pioneering work of the German scientist Harald zur Hausen and extensive studies of the role of HPV infection in cervical cancer and other lesions, it has led to the development of standardized HPV tests and prophylactic vaccinations. This book presents for clinicians basic knowledge in the field of HPV infections that underlie these advances. Other important aspects of the book are the discussion of cytological findings in the diagnosis of cervical lesions, potential biomarkers and current molecular tests (DNA and RNA tests) in the early detection of HPV-associated diseases. Although the wide use of the prophylactic vaccine is still under debate currently, the book provides evidencebased guidelines for the prophylactic vaccination against HPV-associated neoplasms. It is a compact and easy-read handbook for understanding HPV infection and HPV-associated diseases. The first two chapters of the book discuss the biology, pathogenesis and epidemiology of HPV and HPV infection, including information about the discovery of the role of HPV infection in cervical cancer. Professor Harald zur Hausen discovered that HPV infections play a causal role in the development of the cervical cancer. Later, he has further categorized the heterogeneity of the HPV viral family and identified that HPV16and 18-subtype are most strongly associated with cervical cancers. The book also includes the classification of the HPV into lowand high-risk subtypes, and their potential roles in oncogenesis and the development of a variety of human diseases. Two examples of the low-risk HPV-infections and associated human diseases are discussed in detail, including condylomata acuminate and recurrent respiratory papillomatosis. In highrisk HPV infections, several neoplasms from different anatomic sites, including the cervix, vulva, vagina, penile, anus and tonsil, are included. Each anatomic site of the lesion is discussed in its own chapter. Each chapter begins with the review of subtypes of HPVs involved in the infection, clinical manifestations and the histomorphology of the lesion, followed by diagnostic tests, therapeutic recommendations and clinical preventions. The actual technique of obtaining the specimen, diagnostic procedures and treatment options are nicely discussed and demonstrated through illustrations and tables. The book devotes four chapters to discussion of the early detection of HPV infections, including the cytological diagnosis of cervical lesions, potential biomarker developments and the state-of-the-art molecular tests. The described knowledge and techniques are clinically relevant and informative. The information is presented in nicely bulleted tables that cover criteria for diagnosis and problems for each technique. For example, in the Concepts of Biomarker Development chapter, it discusses the pros and cons of these biomarkers in clinical practice and summarizes information in an easy-read table format. Similarly, in the discussion of DNA and RNA tests, the test system, the name of the company providing the test, potential HPV subtypes and the target sequence of the virus are summarized in a nicely presented table. Finally, the last chapter of the book discusses the prevention of HPV infections by vaccination. It compares the clinical information of two major types of vaccines, Gardasil and Cervarix. It also provides evidence-based guidelines for prophylactic vaccination against HPV-associated infectious diseases, based on clinical trials worldwide, including trials from Germany, Australia, Costa Rica and other counties. In summary, this book includes basic information of the biology, epidemiology, diagnosis, treatment and prevention of the HPV infection. It is presented in a manner most consistent with real clinical situations for clinicians. Overall, the book is nicely written with a systematic discussion of the diagnosis and prevention of HPV infections. Prophylaxis and Early Detection of HPvrelated Neoplasia

Introduction: Nuclear pseudoinclusions are one of the most specific pathologic features in diagnosing papillary thyroid carcinoma (PTC). However, the biologic nature of these pseudo-inclusions is largely unknown. Beta-catenin is an oncoprotein involved in Wnt signaling pathway which is activated in several malignancies including PTC. Using immunohistochemistry, we studied the expression of beta-catenin in PTC and hyalinizing trabecular adenoma (HTA), with particular focus on its expression in pseudoinclusions, both on histologic sections and on cytologic specimens. Materials and Methods: A cohort of 13 cases, including 8 cases of PTC and 5 cases of HTA, was applied in this study. Beta-catenin immunohistochemitry was performed on histology block recuts and cytology slides of each case. The beta-catenin labeling index of pseudoinclusions was counted in 15 high power fields and calculated in comparison with those counted on immediate next H&E stained histologic slides. Cytology slides were digitally scanned before destaining and restaining with beta-catenin. The number of beta-catenin-labeled pseudo-inclusions was compared with those digitally scanned slides. Results: On histologic sections, neoplastic cells from both PTC and HTA show much stronger membranous staining pattern of beta-catenin, compared to adjacent normal follicles or colloid nodules. However, labeling index of beta-catenin for nuclear pseudo-inclusions is significantly different between PTC and HTA. Strong intranuclear staining of beta-catenin was seen in 93.5% (range of 72-100%) of the pseudoinclusions in PTC, while only 6.4% (range of 0-13%) of pseudo-inclusions in HTA showed positive staining pattern (p

mutated cases were found and all cases with mutations confirmed. No false positive cases were detected. In total, eight specimens (19.5%) showed mutations: six for EZH2 (2 FL, 2 LBCL and 2 DTL), one for CD79B (BL), and one for MYD88 (LBCL). Among them, five cases showed concurrent MYC and/or BCL-2 translocations and two revealed extra copies of BCL-2. In only one case, no gene rearrangements were seen. Conclusions: Archived CPs are a reliable source of high-quality genomic material, with successful results using a high-throughput multiplex mutation platform in cases stored for up to seven years. Almost all B-cell NHL with point mutations showed concurrent chromosomal abnormalities. This study provides further documentation of the potential use of cytological samples for multiple molecular assays and opens the opportunity for their use in large scale studies.