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PURPOSE To report a case of vitreous seeding in a medium-sized choroidal melanoma and review the literature. METHODS Observational case report and review of literature for pathogenesis, role of vitreous biopsy, and treatment outcomes. RESULTS A case of 57-year-old man diagnosed with vitreous seeding in the left eye 1 year after episcleral brachytherapy for medium-sized choroidal melanoma. The patient was initially diagnosed to have subretinal and vitreous hemorrhage due to rupture of a retinal artery macroaneurysm for which focal laser and intravitreal antivascular endothelial growth factor injections were administered. Over the next 9 months, the vitreous hemorrhage cleared and choroidal melanoma with retinal invasion became evident. One year after brachytherapy, the primary tumor regressed with resolution of surrounding subretinal fluid and hemorrhage. However, gradual decline in the visual acuity from 20/50 to 20/500 with increase of pigmented debris over the retinal surface and in the vitreous cavity was noted. A vitreous biopsy confirmed the presence of viable melanoma cells (epithelioid type), and the eye was enucleated. Histopathology showed microscopic persistence of primary tumor with diffuse vitreous seeding. CONCLUSION Vitreous seeding of choroidal melanoma poses a diagnostic and management challenge.

The presence of atypical endometrial cells in the Papanicolaou (Pap) test has been associated with an increased rate of endometrial malignancy, with reported rates ranging from 14% to 47%. However, most reported studies have focused on patients who were aged40 years. The purpose of the present study was to investigate the clinical significance of identifying atypical endometrial cells in Pap test samples in women aged40 years of age.A search of the cytology Pap test database was performed from 2000 to 2014 using the keywords "atypical endometrial cells" or "atypical glandular cells favor endometrial origin" in women aged40 years. The available ThinPrep slides were reviewed. The patients' clinical presentation, follow-up endometrial biopsy findings, treatment, and clinical follow-up data were recorded. Endometrial carcinoma tissue sections were screened for Lynch syndrome.The database search yielded 63 study cases. Of these 63 patients, 52 had subsequently undergone endometrial biopsy. Of the 52 patients with follow-up biopsy findings available, 9 (17.3%) had premalignant (5 with atypical hyperplasia) or malignant (4 with endometrioid adenocarcinoma) lesions. In addition, 16 patients (30.8%) had other endometrial pathologic features. The 9 patients with premalignant or malignant endometrial lesions (8 white, 1 black) were overweight or obese; 3 of the patients did not have any clinical symptoms. All 4 patients with endometrioid adenocarcinoma had negative Lynch syndrome screening findings.Our results suggest that it is important to recognize the presence of atypical endometrial cells in the Pap tests from young patients, given its association with the finding of premalignant and malignant pathologic features in subsequent endometrial biopsies.

Objective One indication of fine-needle aspiration biopsy (FNAB) is the diagnostic confirmatory of a clinical suspicion of uveal metastasis. We analyzed our experience in this clinical setting to assess the effectiveness of FNAB technique. Design Retrospective study. Participants 28 patients (28 eyes) underwent FNAB biopsy. Methods Aspirates were performed using 25-gauge needle and were classified into the following categories: positive, atypical, negative, or nondiagnostic. The electronic medical records provided all clinical data. Subsequent clinical course was considered as the diagnostic standard. Results Subsequent clinical course was metastatic tumour in 19 cases (68%) and nonmetastatic tumour in other 9 cases, considered as the diagnostic standard. Cytological interpretations for metastases were positive in 19 cases (68%), atypical in 2 cases (7%), negative in 4 cases (14%), and nondiagnostic in 3 cases (11%). The metastasis-positive cases included 9 adenocarcinoma, 3 uveal lymphoma, 3 small cell carcinomas, 3 non–small cell carcinomas, and 1 metastatic paraganglioma. Both of the atypical cases were suggestive for non-Hodgkin lymphoma. The 4 negative cases for metastases included 2 true negative cases, and 2 false negative aspirates that subsequently proved to be metastatic adenocarcinoma. The 3 nondiagnostic cases included 1 schwannoma, 1 low-grade uveal non-Hodgkin lymphoma, and 1 metastatic adenocarcinoma. The overall sensitivity for FNAB was 87.5%, with a specificity of 100%. Conclusions FNAB of suspected uveal metastases is a reliable diagnostic technique.

PURPOSE To report cytopathological observations on the cells retrieved from the 25-G cannula used during prognostic transvitreal fine-needle aspiration biopsy of choroidal melanoma. METHODS Transvitreal fine-needle aspiration biopsy of choroidal melanoma was performed through a 25-G valved cannula. Twenty samples from 20 consecutive patients were obtained. Most tumors were treated with plaque radiation therapy (16/20, 80%) following standard clinical guidelines. Four enucleated globes (4/20, 20%) were subjected to a similar transvitreal biopsy before enucleation. RESULTS Cytopathological analysis of the cells retrieved from the cannula revealed the absence of any cells in 4 of 20 samples (20%). In the remaining 16 samples, definite melanoma cells and atypical cells (probable melanoma cells) were observed in 2 samples each (total 4, 25%). Histiocytes (4/16, 25%) and lymphocytes (1/16, 6%) were also observed. Thirteen samples (13/16, 81%) contained conjunctival epithelial epithelium. Prognostication could be performed on all fine-needle aspiration biopsy samples (20, 100%). CONCLUSION Use of a 25-G valved cannula offers potential advantages by isolating the needle tract and by allowing retrieval of the contaminating cells without affecting the prognostic yield of the fine-needle aspiration biopsy sample.

Context Leiomyomas have abundant extracellular matrix (ECM), with upregulation of versican, a large proteoglycan. Objective We investigated ADAMTS (a disintegrin-like and metalloprotease with thrombospondin type 1 motifs) protease-mediated versican cleavage in myometrium and leiomyoma and the effect of versican knockdown in leiomyoma cells. Design We used quantitative reverse transcription polymerase chain reaction (qRT-PCR), western blotting, immunohistochemistry, and RNA in situ hybridization for analysis of myometrium, leiomyoma and immortalized myometrium and leiomyoma cells. Short interfering RNA (siRNA) was used to knockdown versican in leiomyoma cells. Setting This study was performed in an academic laboratory. Patients Study subjects were women with symptomatic or asymptomatic leiomyoma. Main Outcome Measures We quantified messenger RNAs (mRNAs) for versican splice variants. We identified ADAMTS-cleaved versican in myometrium and leiomyoma and ADAMTS messenger RNAs and examined the effect of VCAN siRNA on smooth muscle differentiation and expression of estrogen and progesterone receptors. Results The women in the symptomatic group (n = 7) had larger leiomyoma (P = 0.01), heavy menstrual bleeding (P < 0.01), and lower hemoglobin levels (P = 0.02) compared with the asymptomatic group (n = 7), but were similar in age and menopausal status. Versican V0 and V1 isoforms were upregulated in the leiomyomas of symptomatic versus asymptomatic women (P = 0.03 and P = 0.04, respectively). Abundant cleaved versican was detected in leiomyoma and myometrium, as well as in myometrial and leiomyoma cell lines. ADAMTS4 (P = 0.03) and ADAMTS15 (P = 0.04) were upregulated in symptomatic leiomyomas. VCAN siRNA did not effect cell proliferation, apoptosis, or smooth muscle markers, but reduced ESR1 and PR-A expression (P = 0.001 and P = 0.002, respectively). Conclusions Versican in myometrium, leiomyomas and in the corresponding immortalized cells is cleaved by ADAMTS proteases. VCAN siRNA suppresses production of estrogen receptor 1 and progesterone receptor-A. These findings have implications for leiomyoma growth.

Purpose: To report 3 cases providing insight into clinical progression of reactive retinal astrocytic tumor. Methods: The clinical, imaging, and when available, the cytologic features of 3 cases of reactive retinal astrocytic tumor (focal nodular gliosis) were reviewed. Results: A 6-year-old female, a 49-year-old man, and a 39-year-old man each developed a white retinal mass associated with laser photocoagulation, lattice degeneration, and treatment of a presumed vascular tumor, respectively. All tumors were white, circumscribed retinal masses that tended to be associated with exudation and either initially or eventually minimal vascularity. Conclusion: Reactive retinal astrocytic tumor can be observed in response to a degenerative, inflammatory, or ischemic retinal insult. Such tumors may progress after therapeutic intervention.

Cryptococcal intraocular infection is a rare disease and is usually associated with generalized systemic disease in immunocompromised patients. The diagnosis may be difficult because of the rarity of this disease and its similarities to other uveitic entities. We describe a case of culture-positive cryptococcal iridociliary granuloma diagnosed by anterior chamber tap and fine-needle aspiration biopsy in a 60-year-old immunocompetent woman with acute granulomatous uveitis. She was treated successfully with systemic amphotericin B and fluconazole and intravitreal amphotericin B, with improvement in the inflammation and visual acuity and regression of the iridociliary granuloma. We review previously reported cases of intraocular cryptococcal infection. Cryptococcal iridociliary granuloma should be considered in the differential diagnosis of an atypical iridociliary mass associated with acute uveitis.

Purpose Multiple choroidal melanomas arising in the same eye is a very rare entity, usually leading ophthalmologists to entertain other diagnoses. Historically, the only available treatment reported for this rare entity was enucleation. In this study we demonstrate in a series of patients with multiple simultaneous choroidal melanomas that eye salvage is possible using a variety of radiotherapy techniques. Observations Both patients presented with two simultaneous choroidal melanomas in one eye. The first patient was only 30 years old and presented with two largely amelanotic tumours with large exudative retinal detachment. Cytology from fine needle aspiration biopsies from both tumours with immunohistochemistry confirmed two separate melanomas. Sequential radioactive iodine plaque brachytherapy led to regression of both tumours. The second, older patient's two tumours both had the typical appearance of choroidal melanoma and he underwent proton beam irradiation to the entire field leading to tumour regression. Conclusions Multiple choroidal melanomas can rarely arise simultaneously in the same eye, and despite their variable appearance, a definitive diagnosis can be aided by cytology and immunohistochemistry in atypical-appearing cases. While all other previously reported cases have necessitated enucleation, we demonstrate that globe salvage is possible using either proton beam irradiation to the entire tumour field, or with sequential radioactive plaque brachytherapy.

Biopsy involves the removal of a tissue sample, laboratory analysis, and interpretation of the results. The usual objective of biopsy has been to establish or confirm a diagnosis. For example, intraocular biopsy is useful when clinical examination fails to distinguish a melanoma from a nevus or metastasis. Even when there is a confident clinical diagnosis, biopsy may be performed to determine the tumor subtype. A uveal tumor can be sampled by aspirational, incisional, or excisional biopsy techniques, depending on its size and location in the eye. Close collaboration with the cytopathologist is essential to ensure adequate sample size and handling. Aspiration biopsy is essentially contraindicated if retinoblastoma is a possibility. In this chapter, we review techniques, indications, complications, and the limitations of intraocular biopsies. Techniques for biopsy of conjunctival, eyelid, and orbital tumors are covered elsewhere in their respective volumes.

Immune cell infiltrates within the tumor microenvironment can influence treatment response and outcome in several cancers. In this study, we developed RNA-based immune signatures from pan-cancer analysis that could serve as potential markers across tumor types and tested them for association with outcome in high-grade serous ovarian cancer (HGSOC) and other female cancers. Pan-cancer RNA-Seq cluster analysis of immune-related gene expression profiles in The Cancer Genome Atlas (TCGA) from 29 different solid tumors (4446 specimens) identified distinct but concordant gene signatures. Among these immune signatures, Cytotoxic Lymphocyte Immune Signature (CLIS), T-cell trafficking (TCT), and the TCT to M2 tumor-associated macrophage (M2TAM) ratio (TCT:M2TAM) were significantly (p &lt, 0.05) associated with overall survival (OS), using multivariable Cox proportional hazards regression models, in a discovery cohort and two independent validation cohorts of HGSOC patients. Notably, the TCT:M2TAM ratio was highly significant (p &le, 0.000001) in two HGSOC cohorts. Immune signatures were also significant (p &lt, 0.05) in the presence of tumor cytoreduction, BRCA1/2 mutation, and COL2A1 expression. Importantly, the CLIS and TCT signatures were also validated for prognostic significance (p &lt, 0.05) in TCGA cohorts for endometrial and high tumor mutational burden (Hi-TMB) breast cancer. These immune signatures also have the potential for being predictive in other cancers and for patients following different treatment strategies.

We report two patients who developed a second distinct choroidal melanoma in the same eye following successful regression of their first choroidal melanoma after iodine-125 plaque brachytherapy. Neither patient demonstrated ocular melanocytosis, local tumor recurrence, or vitreous seeding. One patient had the second tumor arising from a previously documented choroidal nevus, and after undergoing enucleation, there was no detectable connection between the tumors on histopathologic examination. Germline BAP1 mutation was absent in both cases. Multifocal primary uveal melanoma is a rare entity in which the second tumor may occur either de novo or from a malignant transformation of a choroidal nevus. Known risk factors include ocular melanocytosis or germline BAP1 mutation. Additional underlying mechanisms have yet to be elucidated.

Background Choroidal and ciliary body melanomas divide into two approximately equal groups. Local therapy cures one group while the other metastasizes and proves lethal. Monosomy 3 strongly associates with aggressive behavior. We analyzed a series of choroidal and ciliary body melanomas to describe the cellular features and to compare them to monosomy 3 status using the latter as a surrogate for survival. Methods One hundred eleven specimens met the study's inclusion criteria. Following ThinPrep processing, samples were analyzed for cellular features including: cell type, nuclear grade, tumor infiltrating lymphocytes, and the presence of necrosis and melanin. FISH analysis for monosomy 3 was performed on ThinPrep slides using a threshold of 20% monosomic cells per 200 melanoma cells. Results Seventy-two tumors (65%) had a mixed cell type while spindle cell type and epithelioid cell type occurred in 37 (33%) and 2 (1.8%), respectively. Seventy-five tumors (68%) had Grade 2 nuclear atypia. Monosomy 3 occurred in 57 tumors (51%). Significantly more tumors with Grade 3 nuclei had monosomy 3 (79% vs.43%, P = 0.002) and metastases (29% vs. 8%, P = 0.01). None of the 11 pure spindle cell tumors with Grade 1 nuclei metastasized or had monosomy 3. Conclusions Uveal melanoma has a relatively consistent cellular appearance, characterized by a mixed cell pattern and no more than moderate nuclear atypia. This consistent appearance aids in the cellular diagnosis but limits prognostication using cellular features. Cellular features significantly associate with monosomy 3 status only in the minority of tumors at the extremes of the morphologic spectrum. Diagn. Cytopathol. 2016. © 2016 Wiley Periodicals, Inc.

Tumor recurrence, following initial response to adjuvant chemotherapy, is a major problem in women with high-grade serous ovarian cancer (HGSOC). Microarray analysis of primary tumors has identified genes that may be useful in risk stratification/overall survival, but are of limited value in predicting the >70% rate for tumor recurrence. In this study, we performed RNA-Seq analysis of primary and recurrent HGSOC to first identify unique differentially expressed genes. From this dataset, we selected 21 archetypical coding genes and one noncoding RNA, based on statistically significant differences in their expression profile between tumors, for validation by qPCR in a larger cohort of 110 ovarian tumors (71 primary and 39 recurrent) and for testing association of specific genes with time-to-recurrence (TTR). Kaplan-Meier tests revealed that high expression of collagen type II, alpha 1 (COL2A1) was associated with delayed TTR (HR = 0.47, 95% CI: 0.27-0.82, p = 0.008), whereas low expression of the pseudogene, solute carrier family 6 member 10 (SLC6A10P), was associated with longer TTR (HR = 0.53, 95% CI: 0.30-0.93, p = 0.027). Notably, TTR was significantly delayed for tumors that simultaneously highly expressed COL2A1 and lowly expressed SLC6A10P (HR = 0.21, 95% CI: 0.082-0.54, p = 0.0011), an estimated median of 95 months as compared to an estimated median of 16 months for subjects expressing other levels of COL2A1 and SLC6A10P. Thus, evaluating expression levels of COL2A1 and SLC6A10P at primary surgery could be beneficial for clinically managing recurrence of HGSOC.

A 72-year-old man presented after a single choroidal mass was incidentally detected on fundus examination of his right eye. The patient has a history of multiple myeloma and neuroendocrine thymoma diagnosed 6 and 10 years before presentation, respectively. Fine-needle aspiration biopsy revealed metastatic choroidal carcinoid tumor. The patient was subsequently treated with brachytherapy (iodine-125).

Purpose To report the cytologic characteristics of uveal melanoma. Design This is a prospective, single-center study of consecutive patients. Subjects All patients with a clinical diagnosis of uveal melanoma from May 2009 to July 2013 who underwent prognostication fine-needle aspiration biopsy (FNAB) were included. Methods The cytologic characteristics of uveal melanoma were analyzed for 150 consecutive patients with a clinical diagnosis of uveal melanoma who were treated at the Cleveland Clinic Cole Eye Institute between May 2009 and August 2012. Main Outcome Measures Cellular features of all cases were analyzed for cell type, presence of melanin, nuclear grade, tumor-infiltrating lymphocytes, and necrosis. Cytology was then correlated with histopathology in enucleated eyes. Results A total of 150 patients were included. Seven samples of tumor resections were excluded from the study because they were studied by impression smears. A total of 143 FNAB samples of 143 patients formed the basis for analysis. Fifty-three percent of the patients were male, and the average age for all patients was 60 years. Transcorneal (n = 8), transscleral (n = 71), and transvitreal (n = 64) approaches were used. Of 143 samples, 131 were adequate. Among these, spindle cells were observed in 98% (63% mixed and 35% spindle only), whereas only epithelioid cells were observed in 2 samples. Melanin granules were observed in 80% of samples. Tumor nuclear grade (atypia) increased with tumor height and by tumor location (least atypia with iris tumors). Conclusions Cytologic features such as spindle cells and melanin granules, present in 98% and 80% of samples, respectively, are important cytologic diagnostic features. Tumor nuclear grade (atypia) increased with tumor height. Iris melanoma has bland features compared with ciliary and choroidal melanoma.

Purpose To report outcomes and complications of fine-needle aspiration biopsy (FNAB) of uveal melanoma performed for diagnostic and prognostic purposes. Methods Prospective interventional case series of 150 consecutive patients with a clinical diagnosis of uveal melanoma. The FNAB approach (transcorneal (TCO), transscleral (TSC) and transvitreal (TVT) was primarily determined by the location of the tumour. The FNAB was performed using a 25-gauge needle using a previously published technique. Prognostication was done using fluorescent in situ hybridisation detection of monosomy of chromosome 3. Results FNAB was obtained via TCO (8), TSC (71) and TVT (64) approach and impression smear in seven cases. Diagnostic yield was 92%. False-negative results were observed in 8%. Diagnostic yield was significantly correlated to biopsy approach (TCO 100%, TSC 96%, TSV 86%; p=0.029) and tumour size (basal diameter >5.0 mm; height >2.5 mm). Persistent haemorrhage (subretinal haemorrhage or vitreous) requiring surgical intervention (1%) and rhegmatogenous retinal detachment (1%) were rare. Endophthalmitis, hypotony, tumour recurrence, episcleral seeding were not observed over the average follow-up of 37 months. Prognostication could be performed in 85% of cases. Overall, only 47% of eligible patients enrolled into the adjuvant therapy trial. Conclusions FNAB for uveal melanoma with 25-gauge needle is a safe procedure that can yield diagnostic and prognostic information in vast majority of cases (92% and 85%, respectively). Even so, only about half of the eligible cases eventually enrolled into the adjuvant therapy trial. Possibility of negative FNAB yield should be considered when counselling patients with small tumours. Alternative means of diagnostic biopsy and methods of prognostication need to be assessed for small tumours.

Objectives Aberrant homeobox (HOX) gene expression is reported in high-grade serous ovarian carcinoma (HGSOC), however, its prognostic significance remains unclear. Methods HOX genes associated with progression-free survival (PFS) in a discovery cohort of primary HGSOC samples with RNA sequencing data, and those previously reported to be associated with clinical outcomes, were selected for qPCR testing in an independent training cohort of primary HGSOC samples ( n =71). A prognostic model for PFS was developed using univariate and multivariate Cox regression. Patients were stratified into risk groups that optimized the test statistic. The model was tested in an independent HGSOC cohort from The Cancer Genome Atlas (TCGA) ( n =320). The effect of selected HOX genes on drug sensitivity and reactive oxygen species (ROS) accumulation was examined in vitro. Results Of 23 HOX genes tested in the training cohort, HOXA4 (HR=1.20, 95% CI=1.07–1.34, P =0.002) and HOXB3 (HR=1.09, 95% CI=1.01–1.17, P =0.027) overexpression were significantly associated with shorter PFS in multivariate analysis. Based on the optimal cutoff of the HOXA4/HOXB3 risk score, median PFS was 16.9months (95% CI=14.6–21.2months) and not reached (>80months) for patients with high and low risk scores, respectively (HR=8.89, 95% CI=2.09–37.74, P HOXA4/HOXB3 risk score was significantly associated with disease-free survival (HR=1.44, 95% CI=1.00–2.09, P =0.048). HOXA4 or HOXB3 overexpression in ovarian cancer cells decreased sensitivity to cisplatin and attenuated the generation of cisplatin-induced ROS ( P Conclusions HOXA4/HOXB3 gene expression-based risk score may be useful for prognostic risk stratification and warrants prospective validation in HGSOC patients.

Lynch syndrome (LS) is a hereditary condition that increases the risk for endometrial and other cancers. Recognizing women at risk for LS based on personal/family history is burdensome and imprecise. Tumor testing using microsatellite instability (MSI) testing and immunohistochemistry (IHC) for mismatch repair protein expression can be an effective strategy for identifying potential LS in patients presenting with colorectal or endometrial cancer. Here we describe our experience implementing a screening program for endometrial cancers.Endometrial cancers diagnosed ≤50 years or those with suspicious personal history or histopathologic features were screened with MSI/IHC, June 2009-June 2011. Criteria were later (July 2011-July 2012) expanded to patients diagnosed60 years, or at any age with suspicious features, and finally (after August 2012) universal screening was implemented. Screening techniques began with both MSI and IHC for every tumor, and later converted to IHC for two proteins, and MLH1 promoter methylation analysis when indicated. A genetic counselor contacted patients directly to offer genetic counseling appointments.Two hundred and forty-five endometrial cancers (average age, 57 years) were screened. Sixty-two patients (25%) had abnormal results, and 42 patients were referred for genetic counseling. Of the 42 patients, 34 underwent genetic counseling, 28 pursued genetic testing, and 11 were diagnosed with LS. When age and pathology criteria were used, 27 eligible cases were overlooked for screening and 3 cases of LS were found only because a clinician requested screening.Universal screening of endometrial cancers for LS is practical and successfully implemented with collaboration among genetic counselors, gynecologic oncologists, and pathologists.

Purpose The aim of this study was to describe a case of iris melanoma diagnosed by fine-needle aspiration biopsy (FNAB) with review of the literature. Design This study presents a case report and review of the literature. Methods A 76-year-old white man presented with iris melanoma arising from preexisting iris nevus that was confirmed cytologically by a transcorneal FNAB. Results A pigmented lesion on the left iris extending from 3 to 8:30 o'clock, from the iris root to the pupillary margin without ectropion uveae, was biopsied through 1-mm clear corneal incision. A short 25-gauge needle was inserted into the tumor while applying aspiration, and 10-0 suture was used to close the wound. Cytopathology confirmed the presence of spindle-shaped cells with conspicuous cytoplasmic melanin and nuclear atypia consistent with the diagnosis of melanoma. There were no intraoperative or postoperative complications. The patient was subsequently treated with radiation plaque brachytherapy. Conclusions Although indicated only in minority of cases, it is important to consider FNAB for the diagnosis and management of iris lesions.

Background Differentiation between the various pathologies presenting as a cystic pancreatic lesion is clinically important but often challenging. We have previously advocated the performance of endoscopic ultrasound (EUS) with aspiration and determination of mucin and carcinoembryonic antigen (CEA) content. We sought to report the results of this ongoing protocol and determine the relative importance of cyst fluid mucin and CEA for the diagnostic process. Methods The institutions prospectively maintained pancreatic cyst database was accessed to identify patients who had undergone pancreatic EUS and cyst aspiration as part of their evaluation. Only those patients who had subsequently undergone resection were selected, with histopathology being the gold standard for comparison. Results From January 2000 to July 2009, 174 patients with pancreatic cystic disease underwent surgery, 121 of whom had an EUS with aspiration attempted at our institution with specimens sent for mucin and CEA. Based on histopathology, 86 mucinous lesions were identified, including 44 cystadenomas, 34 intraductal papillary mucinous neoplasms, 7 mucinous adenocarcinomas, and 1 intraductal oncocytic papillary neoplasm; 42 were nonmucinous lesions. The median cyst CEA levels were significantly higher in the mucinous lesions group at 850 versus 2 ng/mL (P = .001). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive diagnostic likelihood ratio, and negative diagnostic likelihood ratio (NDLR) were calculated respectively for mucin alone (0.80, 0.40, 0.61, 0.63, 1.33, 0.68); CEA alone (0.93, 0.43, 0.51, 0.91, 1.63, 0.16); cytology alone (0.38, 0.9, 0.92, 0.31, 3.67, 0.69); mucin or CEA (0.83, 0.65, 0.87, 0.57, 2.51, 0.26); mucin or CEA or cytology (0.92, 0.52, 0.86, 0.68, 1.91, 0.15); mucin plus CEA (0.96, 0.34, 0.25, 0.97, 1.45, 0.12); mucin plus cytology (0.25, 0.97, 0.96, 0.29,7.25, 0.78); CEA plus cytology (0.12, 1.00, 1.00, 0.26, ∞, 0.88); and mucin plus CEA plus cytology (0.08, 1.00, 1.00, 0.25, ∞, 0.92). Conclusion Assessment of cyst mucin and CEA are complementary, with the best profile obtained when both markers are determined along with cytology. This combination provides a good sensitivity, PPV, and NDLR, as well as reasonable PPV and PDNR.

Endometriotic foci, especially ovarian ones, with epithelial cytologic atypia may be precursors of cancer. This study presents an overview of the atypical cytological and histopathological findings associated with endometriosis. Six cases of endometriosis, with atypical histological and cytological changes, were obtained from the archives of the Department of Pathology at Cleveland Clinic Foundation between year 2000 and 2003. The size of the base from which these cases were drawn was 2000 cases of endometriosis. The age range of the patients was from 29 to 52 years. The clinical presentations included infertility (three cases), pelvic pain (three cases), adenexal and pelvic masses (four cases). Stage IV endometriosis with extensive pelvic involvement was found in two patients. Intraoperatively, the endometriotic lesions involved the ovaries (all cases); Cul de sac (four cases); urinary bladder (two cases); sigmoid colon, hemidiaphragms, and uterine vessels (one case each). The endometriotic lesions were associated with uterine leiomyomas (two patients) and adenocarcinoma of the vagina (one patient). Histologically, in addition to endometrial type glands and stroma, usually found in endometriosis, we observed both cytologic and pattern atypism involving the epithelium in all cases. The features of cytologic atypia included nuclear stratification, hyperchromatism, and pleomorphism. The features of pattern atypia were complex glandular pattern, papillary formations and psammoma bodies. In two cases, these features were sufficient for diagnosis of borderline Mullerian seromucinous tumours. One patient had recurred with metastatic adenocarcinoma of the vault. She died later from disseminated metastatic disease. There is a rare association between pelvic endometriosis and borderline ovarian tumours (three cases), cytologic and pattern atypia (two cases); mesothelial hyperplasia, endosalpingiosis (two cases), and metastasis (one case). Cytologic and pattern atypia can develop in the endometriotic foci and therefore, these lesions should be thoroughly scrutinized for presence of these changes. Our findings recommend surgical excision of these foci rather than their simple cauterization.

Uveal melanoma arises from melanocytes of the uveal tract (iris, ciliary body, and choroid) and represents the most common intraocular malignancy in adults. The mean age-adjusted incidence of uveal melanoma in the USA is approximately 4.3 new cases per million people, with no clear variation by latitude. Males have a higher incidence than females (4.9 vs. 3.7 per million). Uveal melanoma is diagnosed mostly at older ages, with a progressively rising, age-specific, incidence rate that peaks near the age of 70 years. Diagnosis often occurs late in the course of disease, and prognosis is generally poor.

A proportion of patients under surveillance for recurrent bladder carcinoma with no immediate evidence of bladder tumor recurrence have positive multitarget fluorescence in situ hybridization (FISH; UroVysion, Vysis, Downers Grove, IL) results. The course of these "anticipatory positive" cases and the time to bladder tumor recurrence remains unknown. We followed up 250 patients with urine cytologic results, concurrent multitarget FISH, and cystoscopic examination for recurrent urothelial carcinoma. Of 81 cases (32.4%) with FISH-positive results, tumor recurrence developed in 60 (74.0%). Of 169 (67.6%) FISH-negative cases, recurrent urothelial carcinoma developed in 22 (13.0%). Of 211 patients (84.4%) with negative cystoscopic examination results, 56 (26.5%) had positive FISH results, and in 35 (62.5%) of these patients, recurrent urothelial carcinoma developed. Approximately 27% of patients under bladder carcinoma surveillance without immediate evidence of tumor recurrence will have a positive FISH result, defining the anticipatory positive subset. In about 65% of this anticipatory positive group, recurrent bladder urothelial carcinoma developed within 29 months.

Choroidal and ciliary body melanomas divide into two approximately equal groups. Local therapy cures one group while the other metastasizes and proves lethal. Monosomy 3 strongly associates with aggressive behavior. We analyzed a series of choroidal and ciliary body melanomas to describe the cellular features and to compare them to monosomy 3 status using the latter as a surrogate for survival.One hundred eleven specimens met the study's inclusion criteria. Following ThinPrep processing, samples were analyzed for cellular features including: cell type, nuclear grade, tumor infiltrating lymphocytes, and the presence of necrosis and melanin. FISH analysis for monosomy 3 was performed on ThinPrep slides using a threshold of 20% monosomic cells per 200 melanoma cells.Seventy-two tumors (65%) had a mixed cell type while spindle cell type and epithelioid cell type occurred in 37 (33%) and 2 (1.8%), respectively. Seventy-five tumors (68%) had Grade 2 nuclear atypia. Monosomy 3 occurred in 57 tumors (51%). Significantly more tumors with Grade 3 nuclei had monosomy 3 (79% vs.43%, P = 0.002) and metastases (29% vs. 8%, P = 0.01). None of the 11 pure spindle cell tumors with Grade 1 nuclei metastasized or had monosomy 3.Uveal melanoma has a relatively consistent cellular appearance, characterized by a mixed cell pattern and no more than moderate nuclear atypia. This consistent appearance aids in the cellular diagnosis but limits prognostication using cellular features. Cellular features significantly associate with monosomy 3 status only in the minority of tumors at the extremes of the morphologic spectrum.

Tumor recurrence, following initial response to adjuvant chemotherapy, is a major problem in women with high-grade serous ovarian cancer (HGSOC). Microarray analysis of primary tumors has identified genes that may be useful in risk stratification/overall survival, but are of limited value in predicting the70% rate for tumor recurrence. In this study, we performed RNA-Seq analysis of primary and recurrent HGSOC to first identify unique differentially expressed genes. From this dataset, we selected 21 archetypical coding genes and one noncoding RNA, based on statistically significant differences in their expression profile between tumors, for validation by qPCR in a larger cohort of 110 ovarian tumors (71 primary and 39 recurrent) and for testing association of specific genes with time-to-recurrence (TTR). Kaplan-Meier tests revealed that high expression of collagen type II, alpha 1 (COL2A1) was associated with delayed TTR (HR = 0.47, 95% CI: 0.27-0.82, p = 0.008), whereas low expression of the pseudogene, solute carrier family 6 member 10 (SLC6A10P), was associated with longer TTR (HR = 0.53, 95% CI: 0.30-0.93, p = 0.027). Notably, TTR was significantly delayed for tumors that simultaneously highly expressed COL2A1 and lowly expressed SLC6A10P (HR = 0.21, 95% CI: 0.082-0.54, p = 0.0011), an estimated median of 95 months as compared to an estimated median of 16 months for subjects expressing other levels of COL2A1 and SLC6A10P. Thus, evaluating expression levels of COL2A1 and SLC6A10P at primary surgery could be beneficial for clinically managing recurrence of HGSOC.

T ase Presentation Dr Shah: A 63-year-old man with a 5-pack-year smoking history presented to ur institution for management of progressive dyspnea. He was diagnosed with ronchial asthma yet had not responded to inhaled -agonists or oral steroids. His ast surgical history was significant for cervical laminectomy 9 years ago and left ye vitrectomy 1 year ago. His medical history was significant for adult-onset diabetes ellitus, hypertension, and hyperlipidemia. He also had remote exposure to tuberculosis nd 2 episodes of pneumonia over the past 24 months. Physical examination revealed xpiratory, as well as inspiratory, stridor throughout both lung fields without rales or onchi. Baseline laboratory tests were significant for a blood glucose level of 210 mg/dL, blood urea nitrogen level of 50 mg/dL, and a creatinine level of 2.4 mg/dL. Forced xpiratory volume in 1 second, forced vital capacity, forced expiratory volume in second/forced vital capacity, and diffusion capacity, were 20%, 86%, 70.3%, and 4% of predicted values, respectively. Resting oxygen saturation was normal. Configration of the flow-volume loop was suggestive of variable intrathoracic upper airway bstruction, with reduction in peak expiratory flow to 22% of predicted value. Dr Karnak: Dr Shah, could you please describe the radiographic and chest omputed tomographic (CT) findings? Dr Shah: The chest radiograph showed a 2 2.5–cm opacity projected over the istal trachea on the frontal view; the lateral view was unremarkable. The nonconrast axial CT image at the level just above the carina (Figure 1) and th tructed midline sagittal and coronal image (Figure 2) in soft tissue windows demon trated a lobulated transmural solid mass involving the distal anterior tracheal wall .5 cm proximal to the carina. The 3.2 2.2 3.2–cm extraluminal pretracheal omponent was coarsely calcified, whereas the 2.2 2.3 1.6–cm endobronchial omponents predominantly exhibited soft tissue density, with only a thin rim of alcification at its interface with the distal anterior tracheal wall. There was nearotal occlusion of the distal trachea. The differential diagnosis included primary racheal neoplasm (eg, squamous cell carcinoma, adenoid cystic carcinoma, bronhial adenoma, and carcinoid tumor) or metastasis (breast cancer, renal cell carcioma, colon carcinoma, or melanoma). Tracheal chondroma and paratracheal nerve heath tumor were believed to be less likely possibilities, given their lower incidence. Dr Shah: Drs Mehta and Karnak, could you describe the bronchoscopic examnation and intervention? Dr Karnak: Flexible bronchoscopy revealed a lobulated, smooth, exophytic ass located approximately 2 cm above the carina and producing 80% obstruction f the tracheal lumen. When the bronchoscope was negotiated beyond the obstrucion, there was no evidence of distal disease. Dr Mehta: By using an electrocautery snare through the flexible bronchoscope fter achievement of general anesthesia, the endobronchial portion of the tumor was esected (Figure 3).

The objective of this study was to describe histologic healing patterns of bladder injuries during laparoscopic hysterectomy. This was a prospective experimental analysis (Canadian Task Force classification II-1) performed at the Cleveland Clinic Foundation, Minimally Invasive Surgery Center animal laboratory using virgin female mongrels. Sixteen animals divided into groups of four underwent laparoscopic hysterectomy and bladder injury. In group 1, the bladder injury consisted of a 1-cm bladder base injury with bipolar electrosurgical current. In group 2, suture placement through full thickness bladder was performed during closure of the vaginal cuff. A 1-cm bladder base laceration with monopolar cautery was induced and repaired laparoscopically in group 3; group 4 underwent a similar injury to that of group 3 but the repair incorporated full thickness anterior vaginal cuff. Animals were euthanized at least 28 days after the surgery; the bladders and vaginas were harvested en bloc for histologic tissue preparation. Histologic qualifications of inflammation, fibrosis, granuloma formation, necrosis, cautery artifact, granulation tissue, the presence of arteritis, recanalization thrombus, foreign body giant cells, and fistula formation were evaluated at the sites of bladder injury. When analyzed separately, the difference in these post-injury histologic manifestations was not statistically significant. The same was true when comparison was made between groups 1 and 2 (no bladder laceration) vs groups 3 and 4 (monopolar-induced bladder base lacerations). After a healing period of at least 28 days, the histologic manifestations of the various bladder injuries in all groups are similar.

The optimal treatment for incidental asymptomatic pancreatic cysts is not known. The purpose of this study was to determine whether nonmucinous cysts by cyst-aspiration analysis can be observed safely.A prospective protocol was initiated in September of 1999 for all suspected cystic neoplasms. Asymptomatic patients with negative cyst aspirates (no extracellular mucin, and concentration of carcinoembryonic antigen in the cyst fluid200 ng/mL) were followed-up clinically and radiographically.Through December 2004, 221 patients have been evaluated, and 80 (36%) initially were operated. There were 141 (64%) patients with indeterminate cysts, 98 have been followed-up for more than 12 months. Compared with resected patients, observed patients were older (62 vs 56 y, P.006), and had smaller cysts (2.4 vs 4.0, P = .001). At a mean follow-up period of 24 months, 4 patients (4%) were resected. The indication, time to resection, and pathology were as follows: 2 patients for symptoms (abdominal pain and obstructive jaundice) at 24 and 72 months, respectively: mucinous and serous cystadenomas; 1 patient for an increase in size (6.6 to 7.8 cm) at 18 months: lymphoepithelial cyst; and 1 patient for abdominal pain and increase in size (2.0 to 3.7 cm) at 41 months: pseudocyst. The only patient resected for a mucinous neoplasm had a cyst fluid carcinoembryonic antigen level of 896 ng/mL. In the remaining observed patients, 20 (23%) showed a decrease in cyst size, and 16 (19%) showed an increase in size (mean diameter change, 21%).Initial follow-up evaluation indicates that asymptomatic patients without evidence of a mucinous neoplasm by cyst aspiration can be followed clinically and with interval imaging.

We report the clinical trial studies for the ThinPrep Imaging System (TIS; Cytyc, Boxborough, MA). Between December 2000 and July 2001, 10,742 ThinPrep specimens were collected at 4 US clinical sites representative of the normal clinical population of the laboratories, including screening patients and referred patients. After nonstudy screening diagnoses were completed, the vials were relabeled and randomized, and study slides were prepared and stained. TIS-trained cytotechnologists and pathologists screened the slides twice, first manually, then TIS-assisted after an appropriate interval. Afterward, 3 independent pathologists performed an adjudication study to determine definitive diagnoses for the nonnegative slides and 5% of the negative slides; the adjudicated diagnoses served as the "gold standard" for subsequent sensitivity and specificity analyses. TIS-assisted screening was statistically more sensitive than manual screening for atypical squamous cells of undetermined significance (ASCUS) or higher (+) and statistically equivalent for low- (LSIL)+ and high-grade squamous intraepithelial lesion (HSIL)+ diagnoses. TIS-assisted screening had equivalent specificity for ASCUS+ and LSIL+ and significantly higher specificity for HSIL+. Average cytologists' daily screening rates doubled with TIS-assisted screening. The sensitivity of the TIS-assisted screening system equals or exceeds the sensitivity of manual primary screening without adversely affecting specificity, and TIS-assisted screening can improve cervical cancer screening productivity. Cost issues require further study.

We have previously demonstrated the accuracy and reproducibility of a probabilistic/categorical approach for reporting breast fine-needle aspiration (FNA). However, the interobserver agreement in the application of this approach has not been assessed. Twenty breast FNA cases (each on one ThinPrep slide) were pulled from the cytology files of Beth Israel Deaconess Medical Center. The cases included benign epithelial proliferative lesions (6), DCIS (4), and infiltrating carcinoma (10), as shown by subsequent histology. Six pathologists with 14-25 yr of experience in interpreting breast FNA and 0-8 yr of experience with ThinPrep preparations rendered diagnoses according to the probabilistic approach. The kappa statistic for the unremarkable/proliferative, atypical, suspicious, and positive categories were 0.64, 0.08, 0.43, and 0.75, respectively (P < 0.001 for all except for the atypical category [P = 0.09]). Spearman's rho correlating the individual pathologist's diagnosis and the histologic diagnosis ranged from 0.51 (P = 0.02) to 0.78 (P < 0.0001). This was not correlated with the pathologists' years of experience interpreting breast FNA (P = 1.0) or with their years using ThinPrep preparations for breast FNA (P = 0.96). In conclusion, the interobserver agreement was excellent for the positive category in the probabilistic approach, poor for the atypical category, and fair to good for the other categories. The specific level of experience interpreting breast FNA or using ThinPrep among experienced pathologists did not seem to influence their accuracy in reporting the cases in our study.

PURPOSE To report a patient with bilateral choroidal metastasis from a malignant paraganglioma. METHODS Clinicopathologic case report and literature review. RESULTS A 68-year-old woman presented with bilateral amelanotic focal choroidal lesions. A thorough systemic work-up for a primary cancer revealed a paraganglioma (extraadrenal pheochromocytoma) and a pheochromocytoma of the left adrenal gland. Fine-needle aspiration biopsy of the choroidal lesion was consistent with metastatic paraganglioma. CONCLUSION Metastatic paraganglioma, although rare, has the ability to metastasize to the choroid.

The multitarget fluorescence in situ hybridization (FISH) probe set UroVysion (Vysis, Downers Grove, Illinois), containing probes to chromosomes 3, 7 and 17, and to the 9p21 band, has been recently shown to have high sensitivity and specificity for detecting transitional cell carcinoma. In this study we retrospectively tested 120 urine samples from patients with atypical, suspicious and negative cytology for whom concurrent and followup bladder biopsy data were available. We evaluated the ability of FISH to identify malignant cells in cytologically equivocal or negative cases.Archived slides from 120 voided (47) or instrumented (73) urine cytology specimens from patients with concurrent bladder biopsy and a minimum of 12 months of biopsy followup were subjected to hybridization with UroVysion. The cohort included patients with biopsy proven transitional cell carcinoma, which was grades 1 to 3 in 23, 35 and 24, respectively, and stages pTis in 3, pTa in 64, pT1 in 6, pT2 in 6 and pT4 in 3, while it showed negative histology in 38. Cytology findings were suspicious, atypical and negative for transitional cell carcinoma in 31, 49 and 40 cases, respectively. A positive FISH result was defined as 5 transitional cells or greater with a gain of 2 or more of chromosomes 3, 7 or 17, 12 cells or greater with 9p21 deletion, or 10% or greater of cells with isolated trisomy of 1 of chromosomes 3, 7 and 17.All except 12 of the 82 biopsy proven transitional cell carcinoma cases (11 pTa and 1 pT1 tumors) were positive by FISH (85% sensitivity). Sensitivity in patients with suspicious, atypical and negative cytology was 100%, 89% and 60%, respectively. Nine patients with atypical cytology had positive FISH in the setting of a negative concurrent bladder biopsy. However, 8 of these 9 patients (89%) had biopsy proven transitional cell carcinoma within 12 months following the date when the sample tested by FISH was obtained. The last of these patients with false-positive results had previously documented pTis disease, which was also present in the next bladder biopsy 15 months following the positive FISH result. The remaining 29 specimens from patients with negative biopsy and a negative 12-month followup tested negative by FISH (97% overall specificity).The UroVysion FISH assay provides high sensitivity and specificity to detect transitional cell carcinoma in cytologically equivocal and negative urine samples. These results emphasize the important role of this assay in the management of bladder cancer.

Objective To test the feasibility of transplanting an intact frozen-thawed ovary with microvascular anastomosis of the ovarian vascular pedicle to the deep inferior epigastric vessels. Design Chronic survival study. Setting Biological Resources Unit, The Cleveland Clinic Foundation. Animal(s) Adult merino ewes. Intervention(s) Bilateral laparoscopic oophorectomy was performed on 17 synchronized ewes. In one group of animals (Group I, n=11), both ovaries were cryopreserved intact with their vascular pedicles. In another group of animals (Group II, n=6), ovarian cortical strips were prepared from each ovary and cryopreserved. After thawing, follicular viability and apoptosis rates were assessed using one ovary. The other ovary was transplanted to the abdominal wall with microvascular anastomosis (Group I). In Group II, the ovarian cortical strips were placed in the anterior abdominal wall. Ovaries were harvested after 8–10 days in situ and subjected to histological evaluation. Main outcome measure(s) Blood flow, apoptotic signals, follicular viability, serum estradiol (E 2 ), follicle-stimulating hormone (FSH), and histology. Result(s) No significant differences were found in the mean values of apoptosis (mostly in the atretic and some secondary follicles) and follicular viability in both groups. In Group I, immediate and long-term patency were documented in 100% and 27% (3/11) of the grafts, respectively; and postoperative FSH levels were similar to preoperative values in animals with patent vessels. In Group II, postoperative FSH levels were significantly higher than the preoperative ones ( P =.03). Conclusion(s) Transplantation of an intact frozen-thawed ovary is technically feasible. Using this approach, immediate restoration of vascular supply and ovarian hormonal functions is possible.

Background. Optimal management of pancreatic cystic neoplasms includes identification and resection of mucinous neoplasms. This study was performed to assess the accuracy of preoperative variables in determining a mucinous lesion. Methods. Patients referred for a cystic neoplasm were prospectively assessed by presenting symptoms, blinded radiologic review, and endoscopic ultrasound-guided cyst aspirate analysis. Patients who were symptomatic, or had aspirate findings of a mucinous neoplasm were resected. Results. Eighty-seven patients were enrolled over a 22-month period ending in December 2001. There were 56 (64%) women and 31 (36%) men, with a mean age of 63 (27-86) years. Thirty-five (40%) patients were resected including 24 (69%) women and 11 (31%) men with a mean age of 58 years. Twenty-eight (80%) patients who had resection were symptomatic. Specimen histology included 18 (51%) mucinous neoplasms, 8 (23%) serous neoplasms, 4 (11%) ductal or neuroendocrine carcinomas, and 3 (9%) pseudocysts. The positive predictive value (PPV) for cyst-aspirate extracellular mucin (83%) was significant in predicting a mucinous neoplasm (P =.009). No other aspirate variables (amylase, carcinoembryonic antigen, CA15-3, viscosity), or patient characteristics were predictive of final histology. Diagnostic agreement between all 3 radiologists was 8% (P =.98). At a median follow-up of 12 months, no patients who were observed required resection. Conclusions. Patients with suspected pancreatic cystic neoplasms can be selectively treated on the basis of symptoms and cyst-aspirate mucin analysis. Symptomatic and mucin containing lesions should be resected. Surgery 2002;132:628-34.

Objective. The objective of this study was to study further the management of cervical adenocarcinoma in situ (AIS) with particular regard to the results of conservative management without hysterectomy and the use of large loop excision of the transformation zone (LLETZ). Methods. Based upon the files of the Pathology Department at the Cleveland Clinic Foundation, recently encountered AIS patients were combined with patients from a previous study that ended in 1994. Charts and clinical materials were retrospectively reviewed and abstracted. Results. Fifty-two patients were identified for a combined study group of 98 patients. The mean age was 37 years. Fifty-two percent were identified due to abnormal squamous elements on a Pap smear and 43% due to abnormal glandular cells. In patients treated with hysterectomy, 67% were found to have residual disease following conization with positive margins including 3 patients with invasive cancer. Among all patients, LLETZ was associated with a positive margin rate of 57.1% vs 27.3% with cold knife conization (CKC) (χ 2 , P = 0.008). Among patients treated conservatively with conization, the rates of positive margins were 40.0 and 20.0%, respectively, for LLETZ and CKC (χ 2 , P = 0.11); 9.5% of conservatively managed patients with negative initial conization margins eventually had recurrent AIS. Conclusion. Cold knife conization is the preferred method of management for cervical AIS patients selecting conservative treatment. Despite initial conization margins being uninvolved, such patients have an approximate risk of 10% for recurrent AIS.

Objective: To test the feasibility of transplanting an entire ovary with anastomosis of the ovarian vascular pedicle. Design: Long-term survival study. Setting: Biological Resources Unit, Cleveland Clinic Foundation. Animal(s): Five adult, nonpregnant ewes. Intervention(s): Laparoscopic bilateral oophorectomy was performed. Ovaries were autotransplanted into the abdominal wall, and microsurgical vascular anastomosis of the ovarian to the inferior epigastric vessels was performed. The transplant was removed and evaluated after 7 ± 1 days. Main Outcome Measure(s): Blood flow, serum E 2 and FSH levels, and histologic characteristics. Result(s): At follow-up three transplants were viable; they showed no signs of necrosis, and patency of the vascular anastomosis was confirmed. Serum E 2 levels did not change significantly after transplantation in the patent vessel group (155.3 ± 46.1 vs. 125.7 ± 44.6 pg/mL) or the nonpatent vessel group (99 vs. 158 pg/mL). Serum FSH level in the patent vessel group did not change significantly from before to after transplantation (70.6 ± 37.2 ng/mL vs. 95.1 ± 17.7 ng/mL), whereas a large increase in FSH level was observed in the nonpatent vessel group (52.3 ng/mL vs. 522 ng/mL). The patent vessel group had significantly more follicles after transplantation than did the nonpatent vessel group (6 ± 1 vs. 1 ± 1). Conclusion(s): In conjunction with improved protocols for cryopreservation, ovarian autotransplantation with vascular anastomosis may be superior to current ovarian tissue banking and grafting techniques.

Background: Aberrant HOX gene expression has been observed in various malignancies; however, their role as a biomarker for recurrence in patients with HGSOC is unknown. We tested the hypothesis that a HOX gene signature is a biomarker for disease-free survival (DFS) in HGSOC patients following primary cytoreductive surgery and adjuvant platinum-based chemotherapy. Methods: A panel of HOX genes associated with DFS in a discovery cohort of 19 HGSOC patients with available RNA-Seq data, and/or previously reported as associated with survival endpoints in the literature, were selected for testing by qPCR using the Fluidigm platform in an independent training cohort of primary tumors from 73 HGSOC patients. Cox proportional hazards model was used to identify HOX genes significantly associated with DFS. A prognostic gene signature was developed based on the combined linear predictor from the final multivariable Cox model. Patients were stratified into risk groups using the optimal cutoff of the linear predictor risk score, whereby the optimal cutoff was defined as the value that maximized the log-rank test statistic. Risk group stratification was further tested for association with DFS in a larger HGSOC dataset (N=414) with similar clinical characteristics from The Cancer Genome Atlas (TCGA). The role of the identified HOX genes in influencing drug sensitivity was examined by overexpressing these genes in a HGSOC cell line, PEO1. Results: Of 23 HOX genes selected for testing in the training cohort, overexpression of HOXA4 (HR=1.21, 95% CI=1.08-1.35, P=0.001) and HOXB3 (HR=1.09, 95% CI=1.02-1.17, P=0.016) were significantly associated with decreased DFS in multivariate analysis. The median DFS in patients with a HOXA4/HOXB3 risk score ≤ the optimal cutoff was > 80 months (not yet reached), whereas the median DFS in patients with a HOXA4/HOXB3 risk score > the optimal cutoff was 16.9 months (HR=7.85, 95% CI=4.19-14.69, P Citation Format: Jai N. Patel, Katherine Miller, James Symanowski, Jalid Sehouli, Chad Michener, Ioana Braicu, Darla Destephanis, Ashley P. Sutker, Eric J. Norris, David Tait, Wendell Jones, Qing Zhang, Chad Livasy, Charles Biscotti, Ram N. Ganapathi, Mahrukh K. Ganapathi. HOXA4 and HOXB3 gene expression signature as a biomarker of tumor recurrence in patients with high-grade serous ovarian cancer (HGSOC) following primary cytoreductive surgery and first-line adjuvant chemotherapy [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 5708. doi:10.1158/1538-7445.AM2017-5708

Glacial acetic acid (GAA) treatment minimizes the risk that bloody ThinPrep (Hologic, Marlborough, MA) Papanicolaou (Pap) test samples will be unsatisfactory for diagnosis. In our experience, GAA treatment also adversely affects the morphologic appearance of endocervical glandular cells. We analyzed a series of 92 consecutive GAA-treated Pap tests interpreted as atypical endocervical cells (AECs) and compared these with a control group of 130 samples with AECs in Pap tests that had not been treated with GAA to determine if GAA treatment increases the false-positive diagnosis of AECs. By using search data, the rates of AEC interpretations in the GAA-treated and GAA-untreated samples were calculated. Follow-up data, including human papillomavirus results and follow-up cytology and surgical pathology results, were collected. The GAA group had significantly fewer lesions on follow-up surgical pathology examinations than did the control group (6/69 [9%] vs 28/110 [25.5%]; P < or = .01). In our experience, GAA treatment increases the false-positive diagnosis of AECs.

Limited data exist concerning the cellular features of the ThinPrep® (Cytyc Corp., Boxborough, MA) technique in the analysis of breast fine-needle aspiration specimens. Therefore, we analyzed a series of 75 surgically excised palpable breast masses and compared ThinPrep and conventional smear fine-needle aspiration preparations. Each mass was aspirated twice. The first sample was used for two alcohol-fixed conventional smears, and the second sample was rinsed into CytoLyt (Cytyc Corp., Boxborough, MA) solution for processing into a ThinPrep slide. The paired slides were separated and independently analyzed for adequacy, overall cellularity, single epithelial cells (absent, rare, moderate, or numerous), epithelial architecture (sheets or three-dimensional clusters), myoepithelial cells and stripped bipolar nuclei (present or absent), and nuclear detail (poor, satisfactory, or excellent). Each sample was classified as negative, negative consistent with fibroadenoma, atypical favoring benign, atypical favoring malignant, or positive for malignant cells. The 75 breast masses included 32 carcinomas and 43 benign lesions. Four conventional smears and one ThinPrep were unsatisfactory. Significantly, more conventional smears were limited by drying artifact (9 vs. 0). ThinPrep aspirates of carcinomas had better nuclear detail (P = 0.03) and greater cellularity (P = 0.05). ThinPrep aspirates of benign masses had greater epithelial cellularity (P = 0.007) and better nuclear detail (P < 0.001), and more specimens had myoepithelial cells (P = 0.007). The ThinPrep interpretation classified 29 of 32 carcinomas (91%) as positive and three as atypical favoring malignant (sensitivity = 100%). The conventional smear interpretation classified 28 of 31 carcinomas (90%) as positive and three as atypical favoring malignant (sensitivity = 100%). The ThinPrep interpretation classified 42 benign lesions as negative (23 cases), negative consistent with fibroadenoma (8 cases), atypical favoring benign (10 cases), and atypical favoring malignant (1 case) (specificity = 74%). The conventional smear interpretation classified 40 benign lesions as negative (25 cases), negative consistent with fibroadenoma (12 cases), and atypical favoring benign (3 cases) (specificity = 93%). ThinPrep was less specific, but the difference was not statistically significant (P = 0.065). In summary, ThinPrep aspirates had greater cellularity and better nuclear detail than conventional smears, and were just as sensitive in identifying the carcinomas. The difference in specificity between the two techniques was not statistically significant (P = 0.065). Diagn. Cytopathol. 1999;21:137–141. © 1999 Wiley-Liss, Inc.

The aim of this study was to evaluate the 5-year survival probability (SP) of patients treated for ovarian clear cell adenocarcinoma (OCCA) at a single tertiary institution and to compare it to the 5-year SP of patients with other histologic subtypes of epithelial ovarian cancer.Sixty-four patients with pure OCCA treated at the Cleveland Clinic Foundation from 1981 to 1996 were retrospectively identified and clinical information was abstracted. All histologic materials were reviewed by a single gynecologic pathologist. SP was calculated by the Kaplan-Meier method. SPs for OCCA patients were compared to that of other high-grade epithelial ovarian cancer patients in the gynecologic tumor registry. Cox proportional hazards modeling was used to identify varibles associated with decreased SP.The FIGO stages of OCCA study patients were Stage I, 31 (50%), Stage II, 6 (10%), Stage III, 17 (27%), and Stage IV, 8 (13%) (2 patients unstaged). Forty-four patients had no gross residual cancer at the completion of initial surgery while 9 patients had/=1 cm diameter residual and 10 had1 cm residual. Forty-five (73%) received postoperative chemotherapy. The median follow-up for surviving patients is 97 months (range 38 to 209 months). The overall 5-year SP of OCCA patients is 50% with limited disease (Stages I and II) patients having a 5-year SP of 72% versus 17% 5-year SP in patients with advanced disease (P0.001). FIGO stage was most predictive of outcome. The overall 5-year SP of OCCA patients (50%) differed significantly (P0.05) from that of other ovarian cancer registry patients (30%). OCCA patients with limited cancer survived similarly to registry patients (72 vs 72%) as did patients with advanced OCCA compared with registry patients (17 vs 22%).When controlled for grade and stage, the overall survival with OCCA is identical to that of other high-grade epithelial ovarian cancers. Factors that account for the better overall survival of OCCA patients are more favorable disease stage, younger age, and improved debulking status.

To evaluate the occurrence of apoptotic bodies in endocervical adenocarcinoma in situ (AIS) and investigate the relationship of apoptosis to mitotic activity, we performed counts of apoptotic bodies and mitotic figures in 43 patients with AIS and in a comparable control group with nonneoplastic endocervical glandular epithelium. The ages of the patients with AIS ranged from 27 to 74 years (mean = 40). Mitotic figures were present in all AIS cases, and apoptotic bodies were seen in all but two extremely small lesions. In 28 AIS cases in which lesions were large enough to count 10 consecutive high-power fields (HPF), counts of apoptotic bodies ranged from 1 to 36/10 HPF (mean and median = 16), and counts of mitotic figures ranged from 1 to 53 mitotic figures/10 HPF (mean and median = 18). Counts of apoptotic bodies correlated directly with counts of mitotic figures. The ages of the 28 control patients ranged from 32 to 56 years (mean = 43). Counts of apoptotic bodies in the control cases ranged from 0 to 10 per case (mean = 1.1). Apoptotic bodies were present in only 13 (46%) control cases. The highest counts in these cases ranged from 1 to 6 apoptotic bodies/10 HPF (mean = 2.3). Mitotic figures were present in only 4 (14%) control cases. The counts in these cases ranged from 1 to 3 mitotic figures/10 HPF (mean = 1.8). Counts per 10 HPF were significantly (p0.001) more for AIS cases than for controls for apoptotic bodies and mitotic figures. Our results indicate that apoptotic bodies, as well as mitotic figures, occur almost universally in AIS. Both occur significantly more often and in greater numbers in AIS than in nonneoplastic endocervical glandular epithelium. Apoptotic bodies are a consistent morphologic feature of AIS, and their identification may be diagnostically useful.

Fine needle aspiration biopsy (FNAB) of tumors has a long history. The first intraocular biopsy was performed by Hirschberg in 1868. Since the publication of a major report by Jakobiec in 1979, FNAB is increasingly used in the evaluation of ophthalmic tumors. The safety and reliability of ophthalmic FNAB have been reported by several other investigators with adequacy rates of 88–95 %.

We describe a 64-year-old caucasian man with squamous cell carcinoma of the base of the tongue that metastasized to the choroid. The primary tumor was known to be high risk HPV positive and initially diagnosed as T3N3M0 stage IVB two years prior to presentation. Funduscopy revealed an 18 x 17 x 8.9 millimeter mushroom shaped amelanotic tumor with intrinsic vascularity. Ultrasonography revealed medium to high internal reflectivity with echolucent pockets and a positive angle kappa. Marked intrinsic vascularity and associated retinal detachment was also observed. Fine needle aspiration biopsy was performed and 40cGy where delivered via plaque brachytherapy. Histopathologic and cytologic findings of the primary tumor and of the choroidal tumor, respectively are discussed in detail.

Cytologists increasingly encounter atypical endocervical cells, because of the increasing incidence of endocervical adenocarcinoma and the use of improved endocervical sampling devices. These atypical endocervical cells can cause diagnostic problems, especially in recognizing adenocarcinoma in situ (AIS) and distinguishing it from a variety of nonneoplastic changes. We analyzed 33 cervical smears from 22 patients with confirmed AIS and compared these to 19 cervical smears from 17 patients having atypical endocervical cells of undetermined significance and negative follow-up, including at least one tissue biopsy per case, to further investigate the cytologic features of AIS. The AIS smears typically had crowded three-dimensional cellular aggregates, with markedly hyperchromatic nuclei having altered polarity. Frequently, a minor component of AIS formed strips of distinctly columnar cells or sheets. Individual AIS cells occurred in 22 (67%) smears, but these were usually inconspicuous. The AIS smears also had increased nuclear to cytoplasmic ratios (100%), enlarged nuclei (94%), feathering (88%), rosettes (85%), nucleoli (76%), apoptosis (73%), mitoses (64%), multiple nucleoli (18%), and ciliated atypical cells (3%). Cytologic features occurring significantly (P ≤ 0.001) more often in AIS cases were a predominance of three-dimensional crowded aggregates (79% vs. 32%), altered nuclear polarity in most groups (88% vs. 16%), marked hyperchromasia (91% vs. 16%), apoptosis (73% vs. 26%), an increased nuclear to cytoplasmic ratio (100% vs. 63%), feathering (88% vs. 26%), and individual atypical cells (67% vs. 16%). In summary, we identified a number of architectural and cellular features that occurred significantly more often in AIS cases than in cases having atypical endocervical cells of undetermined significance and negative follow-up. Diagn. Cytopathol. 1997;17:326–332. © 1997 Wiley-Liss, Inc.

BACKGROUND The clinical significance of p53 overexpression in patients with ovarian carcinoma is uncertain. Previous studies have yielded conflicting results and have been hampered by small patient populations, failure to account for other well-known prognostic variables in multivariate analysis, and failure to account for the grade of p53 overexpression. The aim of this study was to investigate the independent prognostic significance of p53 overexpression in patients with primary ovarian epithelial cancer (POEC). METHODS Tumors obtained from 221 patients with primary ovarian epithelial cancer (POEC) (Stages I-IV) were studied for p53 overexpression semiquantitatively by immunohistochemical techniques. The median duration of follow-up of surviving patients was 7 years. The presence or absence and degree of p53 overexpression were correlated with the clinicopathologic features of the study population and overall survival. Survival curves were constructed according to the Kaplan-Meier method, and differences in survival were assessed with the log rank test. The prognostic significance of p53 overexpression for survival was assessed in a multivariate analysis with the Cox proportional hazards model. RESULTS One hundred seven tumors (48.4%) exhibited p53 overexpression. The overexpression was graded as mild in 16.7% of cases, moderate in 5.9%, and strong in 25.8%. p53 overexpression was associated with advanced stage (P = 0.04), higher grade (P = 0.0003), serous histology (P = 0.0018), and patient age > 61 years (P = 0.013). In univariate analysis, p53 overexpression was a significant prognostic factor (P = 0.049 for any degree of overexpression, P = 0.03 for strong overexpression). However, in multivariate analysis, after adjustment for stage and size of residual tumor following cytoreductive surgery, p53 overexpression did not retain statistical significance. Survival curves for patients with different stages and grades of tumor differentiation did not demonstrate a difference in survival among patients with no p53 overexpression, compared with those who demonstrated any degree of p53 overexpression or compared with those who demonstrated strong p53 overexpression. CONCLUSIONS p53 overexpression is not an independent prognostic factor for patients with primary ovarian epithelial cancer. Cancer 1997; 80:892-8. © 1997 American Cancer Society.

BACKGROUND & AIMS: A less costly cancer surveillance method for Barrett's esophagus is desirable. The aim of this study was to compare nonendoscopic balloon cytology with biopsy and brush cytology for detecting dysplasia and carcinoma in patients with Barrett's esophagus. METHODS: Patients in a surveillance program underwent balloon cytology before endoscopy with biopsy and brush cytology. Results of cytology were compared with those of histology. RESULTS: Adequate columnar epithelium was obtained in 52 of 63 (83%) patients with balloon cytology and 59 of 61 (97%) with brush cytology. Balloon cytology obtained abnormal cells in 6 of 8 patients with adenocarcinoma, 2 of 2 patients with high-grade dysplasia, and 2 of 8 patients with low-grade dysplasia. Sensitivity of balloon cytology for high-grade dysplasia or carcinoma was 80% but only 25% for low-grade dysplasia. No patients without dysplasia or carcinoma had abnormal cells. Brush cytology was abnormal in all 11 patients with high-grade dysplasia or carcinoma but only 2 of 9 patients with low-grade dysplasia (sensitivity, 22%). Two of 39 patients without dysplasia had abnormal cells (specificity, 95%). Balloon cytology cost was sixfold less than endoscopy with biopsy. CONCLUSIONS: Balloon cytology detected 80% of patients with high-grade dysplasia or carcinoma when sampling was adequate. Brush cytology data suggest that a more abrasive balloon may improve balloon cytology sensitivity. The potential cost savings of balloon cytology compared with endoscopic cancer surveillance in Barrett's esophagus support further studies of this technique. (Gastroenterology 1997 Jun;112(6):1787-97)