Teaching cytopathology in the undergraduate medical school curriculum: the experience at the University of North Carolina

A formal instructional unit in cytopathology in the 2nd-year medical school pathology course at the University of North Carolina is described. This unit was added to the traditional mechanisms and organ systems instruction in the pathology course to increase the exposure of students to modern diagnostic techniques and informed use of laboratory testing. The unit is presented at the end of the pathology course as a summation of organ systems pathology and an introduction to the clinical practice of one branch of pathology. Two lectures cover the general principles of cytopathology, specimen procurement and adequacy, cytologic findings of common lesions in three organ systems (female genital tract, lung, and breast), specialized techniques, clinical advantages and disadvantages of cytologic techniques, and accuracy. Clinical correlation and appropriateness of testing are stressed. An accompanying laboratory session includes examination of glass slides predominantly prepared from surgical specimens and discussion of clinical cases with experienced cytologists using Kodachrome illustrations of cytologic slides and subsequent histologic and clinical follow-up. Our experience to date suggests that this unit informs students about the role of cytology in modern medical practice and helps to bridge the gap between the basic science of pathology and clinical medicine.     

Ureteroscopic biopsy: technique and specimen preparation

Because tissue samples obtained ureteroscopically are small, the techniques for biopsy and for handling and processing the samples are crucial. Our aim is to describe the biopsy technique in great detail so other centers can reproduce it. Patients were evaluated by retrograde ureteropyelography and ureteroscopy for diagnosis. The entire collecting system was examined using a combination of small-diameter rigid and flexible ureteroscopes. Samples were retrieved by aspiration, saline lavage, or, when possible, biopsy of visible tumor by a basket or cup forceps. Multiple samples were obtained from all patients. Fresh specimens were hand delivered to the cytopathology laboratory, where they were evaluated with the cytospin technique. A cell block was prepared whenever there was any visible tissue in the sample. Since we have practiced this technique of handling specimens, our ability to diagnose and grade upper tract neoplasms ureteroscopically has improved markedly. Use of this technique can improve the diagnostic accuracy of ureteroscopic biopsy.     

Fine needle aspiration cytopathology of malignant lymphoma

Morphologic features allowing the cytopathologist to distinguish a reactive lymph node from a malignant lymphoproliferative disorder and to distinguish Hodgkin lymphoma from non-Hodgkin lymphoma are presented in concert with pertinent immunophenotypic profiles of various lymphomas. The limitations and diagnostic pitfalls of aspiration cytopathology in the diagnosis of lymphoma and lymphoid aspirates are also discussed.     

A comparison of the effectiveness of malignancy detection in body fluid examination by the cytopathology and hematology laboratories

BACKGROUND: Body fluid specimens in many institutions are submitted for cytologic examination as well as for examination in a clinical microscopy or hematology laboratory. The cytology laboratory is generally seen as the standard for detection of malignancy, whereas the clinical microscopy laboratory is often depended on predominantly for cell counting and categorization. METHODS: To analyze the effectiveness of the hematology laboratory at detecting malignant fluids, this study retrospectively analyzed reports on 397 body fluid specimens (cerebrospinal, pericardial, peritoneal, and pleural) that were concurrently submitted over a 12-month period to both the cytopathology laboratory and the hematology laboratory. RESULTS: Thirty-seven (9.3%) of the cases were diagnosed as malignant by at least one of the two examinations. The cytopathology examination reported 27 (73%) of the 37 malignant cases as malignant and 30 (81.1%) as at least atypical (27 malignant and 3 inconclusive), and the hematology examination reported 34 (91.9%) as malignant and 36 (97.3%) as at least atypical. A concordant malignant diagnosis was given by both laboratories in 24 (64.9%) of the 37 cases. CONCLUSIONS: These results show that examination of specimens by the hematology laboratory can provide a highly sensitive diagnostic evaluation in addition to its more customary role of providing timely cell counts.     

Cardiovascular responses in a whirlpool bath at 40 degrees C versus user-controlled water temperatures

Basaloid squamous carcinoma is a distinct variant of squamous carcinoma with a particularly poor prognosis. To our knowledge, there are only two papers in the cytopathology literature which describe this entity. We report the fine-needle aspiration findings of an additional case of metastatic basaloid squamous carcinoma in a cervical lymph node and compare its cytomorphologic features to those observed on touch imprints of the subsequent surgical specimen. Smears of the aspirate showed a mixed lymphoid background with interspersed cohesive clusters of small cells roughly 3 times the size of small mature lymphocytes. Some cells were angulated and others exhibited irregular nuclear contours. The cells were generally hyperchromatic with evenly staining dense chromatin or irregularly distributed coarse chromatin. Focally there was evidence of nuclear molding. On Diff-Quik staining, irregular globules of magenta-stained extracellular dense material were noted within or adherent to the periphery of some clusters or as somewhat linear formations with small epithelial cells clinging to the edges. Abundant mitotic figures and clumps of necrotic tumor were more apparent on touch preps of the subsequent surgical specimen. The differential diagnosis by fine-needle aspiration includes adenoid cystic carcinoma, basal-cell adenocarcinoma, adenosquamous carcinoma, and small-cell carcinoma. If a fine-needle aspirate of a cervical lymph node shows the features described above and the primary tumor is unknown, suggesting the possibility of metastatic basaloid squamous carcinoma may aid clinicians in the search for a primary site, as basaloid squamous carcinoma occurs most frequently at the base of the tongue, hypopharynx, and supraglottic larynx.     

Microbial degradation of xenobiotics in the environment

Biodegradation of naturally occurring organic compounds follows their synthesis. In contrast, man-made compounds, also known as xenobiotics, are often refractory to degradation. The main reason is that they cannot be recognized by naturally present organisms and therefore do not enter common metabolic pathways. The physical and chemical characteristics of the compounds, as well as environmental factors, may influence their biodegradability. Some compounds may be transformed only in the presence of another compound which appears as a carbon and energy source. Very often compounds are degraded sequentially through the activity of a series of different organisms. The main degraders in nature are microorganisms, mostly bacteria and some fungi. These organisms, due to their rapid rates of multiplication and great metabolic potential, are able to adapt to new substrates. Selection of degradative potent microorganisms and their successive adaptation to a naturally persistent compound might be a powerful means for environmental detoxification. Although numerous laboratory experiments have given positive results, very few are applicable on a large scale. It is necessary to select microorganisms or microbial communities capable of controlled degradation of persistent organic chemicals without their transformation to other, more hazardous compounds. Better understanding of metabolic pathways for the biodegradation of specific organic compounds as well as more thorough knowledge of degrading microorganisms will make purposeful application of biodegradation possible.     

Relevance of nucleic acid amplification techniques for diagnosis of respiratory tract infections in the clinical laboratory

Clinical laboratories are increasingly receiving requests to perform nucleic acid amplification tests for the detection of a wide variety of infectious agents. In this paper, the efficiency of nucleic acid amplification techniques for the diagnosis of respiratory tract infections is reviewed. In general, these techniques should be applied only for the detection of microorganisms for which available diagnostic techniques are markedly insensitive or nonexistent or when turnaround times for existing tests (e.g., viral culture) are much longer than those expected with amplification. This is the case for rhinoviruses, coronaviruses, and hantaviruses causing a pulmonary syndrome, Bordetella pertussis, Chlamydia pneumoniae, Mycoplasma pneumoniae, and Coxiella burnetii. For Legionella spp. and fungi, contamination originating from the environment is a limiting factor in interpretation of results, as is the difficulty in differentiating colonization and infection. Detection of these agents in urine or blood by amplification techniques remains to be evaluated. In the clinical setting, there is no need for molecular diagnostic tests for the diagnosis of Pneumocystis carinii. At present, amplification methods for Mycobacterium tuberculosis cannot replace the classical diagnostic techniques, due to their lack of sensitivity and the absence of specific internal controls for the detection of inhibitors of the reaction. Also, the results of interlaboratory comparisons are unsatisfactory. Furthermore, isolates are needed for susceptibility studies. Additional work remains to be done on sample preparation methods, comparison between different amplification methods, and analysis of results. The techniques can be useful for the rapid identification of M. tuberculosis in particular circumstances, as well as the rapid detection of most rifampin-resistant isolates. The introduction of diagnostic amplification techniques into a clinical laboratory implies a level of proficiency for excluding false-positive and false-negative results.     

Fine needle aspiration biopsy of the liver. Principal diagnostic challenges

Fine needle aspiration biopsy (FNAB) is the diagnostic procedure of choice for evaluation of liver lesions. Although primarily applied to malignant disease, it is also used in the evaluation of benign conditions. Improvements in imaging techniques and advances in cytologic interpretations, as well as production of new biopsy needles, have all contributed to the rapid increase in radiologically guided liver FNAB.     

Microwave procedures for electron microscopy and resin-embedded sections

Microwaves now have well-established applications in routine light microscopy. They are employed in tissue fixation and to accelerate a wide spectrum of staining procedures. Besides producing superior preservation of cellular antigens through microwave fixation, this form of irradiation has been employed for antigen retrieval, a procedure that has been a major factor in the optimization of immunolabelling in paraffin sections and cytological preparations. A commercial tissue processor has recently been developed which employs microwaves in a markedly accelerated, one-step processing of tissue blocks, completing the procedure within a fraction of conventional times. Microwaves have also been successfully applied in a variety of molecular techniques such as in situ hybridization and polymerase chain reaction. The adoption of microwaves in electron microscopic procedures has been slower, largely because the requirement for speed in processing is not as great, except in diagnostic samples. However, as this review will show, there are equally as many innovative applications of microwaves in electron microscopy. Microwaves have been employed for rapid processing of fine needle aspiration biopsy samples, in keeping with the requirement for speed in this method of diagnosis. Ultrafast fixation of tissue samples has resulted in the better demonstration of cellular enzymes and proteins. It has been clearly shown that microwave-stimulated on grid staining in uranyl acetate and lead citrate produces more consistent results and without background precipitation. Microwaves can be used to hasten resin polymerization and exposure to microwaves results in antigen retrieval in both resin-embedded thick sections and for immuno-electron microscopy. Immunolabelling shows enhanced sensitivity and the technique is anticipated to contribute greatly to the optimization of immuno-electron microscopy. The potential for greatly accelerated preparation of samples for electron microscopy exists but is yet to be fully realized.     

Characterization of action potential-triggered [Ca2+]i transients in single smooth muscle cells of guinea-pig ileum

Cytology can be a rewarding diagnostic technique in equine practice. The respiratory tract readily lends itself to sampling for cytologic evaluation from the upper to lower regions of the system. This article discusses preservation and staining techniques that will allow the practitioner to present satisfactory samples to the laboratory. General considerations for cytologic analysis are discussed as well as the specific findings for individual disorders of the respiratory tract. The proper use of cytologic findings in conjunction with other diagnostic techniques for the respiratory tract are also discussed.     

EDP registration of the types of tests, working procedures and diagnosis in a department of histopathology. Minimum dataset for assessment of the workload

The aim of the study was to develop a computer-based system for measuring workload in a department of histo- and cytopathology using routine registration of a minimum dataset. A group with representatives from the laboratory technicians, the pathologists and the secretaries defined 18 types of specimens. By studying each step of specimen processing it was shown, that 14 items for technical details could cover all the work done in the department. This information was collected in a computer-based system connected to the hospital network. The measurement of workload is essential for the efficient management of laboratory services. The registration of specimen types and a minimum dataset for specimen processing describes the work done in a department of histo- and cytopathology.     

Variations in the composition of spinal anesthetic solutions: the effects of drug addition order and preparation methods

Adjuvants such as opioids or epinephrine are commonly added in small volumes to multicomponent spinal anesthetic solutions. In this study, we tested the hypothesis that final adjuvant concentrations vary depending on the devices and techniques used to prepare the anesthetic solution. We compared two aspiration devices, the filter needle and the filter straw, in a laboratory study. Two techniques for drawing up and estimating adjuvant volumes were assessed, as was variation in the composition of a model spinal anesthetic solution resulting from intra- and interindividual variability. A model hyperbaric anesthetic solution consisting of tetracaine, dextrose, and methylene blue (MB) as a small-volume tracer solution was studied. The components were drawn up into a syringe through one of two commercially supplied aspiration devices, a filter straw or a filter needle. The effect of the order of aspiration of the components into the syringe was measured by determining the MB concentration in the final solution by optical absorbance. Ten experienced anesthesiologists then prepared samples of the test solution using one of two different techniques to estimate tracer volume in the aspiration syringe. In comparison studies, the MB tracer was added to the hyperbaric solution with a tuberculin syringe. The order of aspiration of the solution components had a large effect on the final concentration of the MB tracer in the ultimate mixture. Variation in the MB concentration was on the order of four- to fivefold. Effects were larger for the filter straw compared with the filter needle. A comparison of 10 anesthesiologists revealed large intra- and interindividual variations in the final composition of the model anesthetic solution. The concentration of tracer added to the mixture with a tuberculin syringe approximated the planned yield. We conclude that the devices and techniques used to prepare mixtures of drugs for delivery to the cerebrospinal fluid may influence the concentrations of drugs in the anesthetic and, thus, the dose supplied to the patient receiving spinal anesthesia. Variation in clinical effects of spinal anesthetics may be attributable, in part, to variation in the composition of the anesthetic. IMPLICATIONS: This laboratory study demonstrates the potential for large variation in the composition of spinal anesthetic mixtures.     

Lymphoproliferative and myeloproliferative disorders

Nomenclature regarding neoplasia of the hematopoietic and lymphoid tissues in the horse is confusing. This article will clarify terminology, and discuss the individual lymphoproliferative and myeloproliferative disorders recognized in the horse. Diagnostic techniques that are useful in cases in which hematopoietic or lymphoid tissue neoplasia are suspected include histochemical staining profiles, bone marrow aspiration, and bone marrow biopsy.     

Experiments on Selective Withdrawal of a Codirectional Two-Layer Flow through a Line Sink

For investigating selective withdrawal problems, laboratory experiments were conducted in a horizontal flume with a co-directional two-layer flow of different density into a line sink. Saline water was used as the fluid of the lower layer instead of sediment-laden turbid water for achieving a steady state. In this study, a trend curve was produced using the data of many runs which were taken under varying conditions from aspiration of both layers to only lower-layer aspiration. An adequate parameter for determining the critical condition was obtained from this trend curve. The critical condition is defined as the beginning or ending of aspiration for the upper layer. Suitable variables for the parameter are also discussed. A theoretical formula is suggested and verified, which is better than a traditional empirical formula for calculating the withdrawal concentration. Effects of slot elevation on the lower layer flow and the thickness of the mixing layer are also discussed.     

Thyroid cancer in pregnant women: diagnostic and therapeutic management

There is considerable literature on the effect of pregnancy on established thyroid cancer. In contrast, there are only isolated case reports of management of thyroid cancer diagnosed de novo during pregnancy. We describe four such patients. We recommend fine-needle aspiration biopsy (FNA) of solitary thyroid nodules found early in pregnancy. When the cytopathology is diagnostic of thyroid cancer, thyroidectomy under local or general anesthesia is advised. The patient should be given levothyroxine in a dose sufficient to keep serum thyroid-stimulating hormone (TSH) low. Serum thyroglobulin is a valuable noninvasive method of evaluating completeness of this therapy. The work-up of a nodule found late in pregnancy is best deferred until after delivery.     

A clinical study of respiratory infection isolating non-pathogenic Neisseria by transtracheal aspiration]

Neisseria species other than N. meningitidis and N. gonorrhoeae are generally regarded as commensal bacterial flora of the oropharynx, and little is known regarding cases of these non-pathogenic Neisseria species in the lower respiratory tract. We clinically examined respiratory tract infections from which non-pathogenic Neisseria species were isolated by transtracheal aspiration (TTA). The incidence of non-pathogenic Neisseria isolated was 54 (15.7%) out of 344 episodes of respiratory tract infections with isolated microorganisms from TTA, and was 17.6%, 15.8%, 14.3% for pneumonia, acute bronchitis, and chronic lower respiratory tract infection, respectively. All 54 episodes were isolated with other microorganisms such as alpha-Streptococcus spp. (75.9%), Haemophilus influenzae (25.9%) and anaerobics (22.2%). The isolation ratio according to the age group increased at 45 years of age or more, but did not increase with the advance of age. Predisposing factors were identified such as overt aspiration, iatrogenic procedure and heavy smoking. Cases without overt aspiration that had fevers of 38 degrees C or more or hypoxemia of less than PaO2 70 torr when detecting non-pathogenic Neisseria were observed more frequently in the aged than the non-aged. The findings suggest the detection of non-pathogenic Neisseria by TTA is influenced by the host state that the fall of microorganisms from the upper to lower respiratory tract cannot be defended or excluded by mucociliary transportation disorder due to underlying disease and smoking, or deterioration of physical status other than overt or silent aspiration.     

Fine needle aspiration biopsy of metastatic malignant melanoma with "rhabdoid" features. Frequency, cytologic features, pitfalls and ancillary studies

OBJECTIVE: To characterize the cytopathology of metastatic malignant melanoma (MM) with "rhabdoid" features, a recently described, rare morphologic variant of MM that can be incorrectly diagnosed in fine needle aspiration (FNA) biopsy. STUDY DESIGN: A retrospective review of all FNA biopsy material with the diagnosis of metastatic MM was performed at two institutions. Only cases with a predominant composition of cells that met criteria defined as "rhabdoid" morphology were selected for study. The cytomorphologic features, immunocytochemistry and clinical features of these cases were reviewed. RESULTS: Of 88 FNA cases previously diagnosed as metastatic MM, 4 (4.6%) had a predominance of cells with rhabdoid features. These cases consisted of scattered atypical cells having enlarged, eccentrically placed nuclei; prominent nucleoli; and a moderate amount of cytoplasm possessing round, globular inclusions in Papanicolaou- and Diff-Quik-stained smears. Immunochemistry showed strong S-100, HMB-45 and vimentin staining in two of four cases. CONCLUSIONS: Metastatic MM may present in FNA biopsy as a poorly differentiated malignancy with rhabdoid features, potentially leading to an incorrect cytologic diagnosis. MM must be considered when evaluating neoplasms with a rhabdoid phenotype. Correlation of the cytologic finding with the clinical history and immunohistochemical studies can help in diagnosing this morphologic variant.     

Acute monoarthritis: a practical approach to assessment and treatment

A basic approach to the patient presenting with acute monoarthritis includes a careful history, a physical examination and a selected battery of laboratory tests and radiographs. Because of the possibility of septic joint, rapid assessment and treatment are required. The most common causes of acute monoarthritis are trauma, crystals (gout and pseudogout) and infection. The most important cause of acute monoarthritis is infection, which must be excluded through the use of diagnostic joint aspiration and culture of synovial fluid.     

Monocytes-macrophages and cytokines/chemokines in fine-needle aspiration biopsy cultures: enhanced interleukin-1 receptor antagonist synthesis in rejection-free kidney transplant patients

BACKGROUND: Monocytes-macrophages are found within kidney allografts during the first days after surgery, where they perform "housekeeping" tasks, participate in postreperfusion injury, and act as antigen-presenting cells, as well as become involved in the effector phase of acute rejection. They also seem to play a prominent role in chronic rejection. We quantified their presence in fine-needle aspiration biopsies and studied the growth factors that, we hypothesized, would mark the different implications of the presence of monocytes-macrophages. METHODS: Fine-needle aspiration biopsies were obtained from 56 adult renal transplants and analyzed for CD14+ using the alkaline phosphatase-anti-alkaline phosphatase procedure. Thirty-three patients were studied on the production of interleukin (IL)-1 receptor antagonist (IL-1ra), IL-6, IL-8, macrophage colony-stimulating factor, monocyte chemotactic protein 1, and macrophage inflammatory protein 1alpha by aspiration biopsies cultures using enzyme-linked immunosorbent assay techniques. RESULTS: CD14+ cells were present at significantly higher numbers in steroid-resistant acute rejections but also during the first days after surgery, especially if acute tubular necrosis was present. We found a significantly higher production of IL-1ra by rejection-free patients compared with acutely rejecting patients, and this difference was already established on day 7 after surgery (10+/-10.5 days before rejection). CONCLUSIONS: Monocytes-macrophages are present at higher numbers in aspiration biopsies of kidney transplant patients suffering either acute tubular necrosis or steroid-resistant rejections, but they are present during the first days after transplant in stable patients, too. The production of IL-1ra is significantly up-regulated in stable patients, which suggests that monocytes-macrophages may constitute an early key factor in the down-regulation of the anti-allograft immune response.     

Modern fertilization techniques

In Germany, some 17.2% of married couples are unintentionally childless. Of these, about one-third have a male factor infertility (with disordered spermatogenesis), which in part is unresponsive to drug treatment. In such cases, assisted reproductive techniques are giving childless couples new hope. The techniques are based on two principles: 1) in vitro improvement in semen quality in the laboratory, and 2) the overcoming of natural barriers to fertilization. The latter includes intra-uterine insemination (IUT), in vitro fertilization and embryo transfer (IVF/ET), gamete intrafallopian transfer (GIFT), subzonal sperm insemination (SUZI), zona pellucida drilling, and intracytoplasmatic injection of sperm (ICSI). ICSI has also used epididymal spermatozoa obtained by microsurgical aspiration (MESA) and sperm extracted from testicular biopsies (TESA). These methods have their own specific indications, contraindications and pregnancy rates. However, assisted conception techniques should not be considered outside the overall situation of the couple, including ethical, sociological, physiological and general medical problems.