Objective : This study was conducted to evaluate the cytomorphological findings and diagnostic accuracy of cytology smears prepared for rapid on-site evaluation (ROSE smears), conventional Papanicolaou staining (Pap. smears), and SurePath liquid-based cytology (SP-LBC) from specimens obtained by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of the pancreas.

Study Design : We performed morphometric image analysis of ROSE smears, Pap. smears, and SP-LBC of specimens obtained from 30 cases of pancreatic cancer, and also conducted a retrospective review of both SP-LBC and squash preparations (ROSE and Pap. smears) of specimens obtained from 166 pancreatic lesions by EUS-FNA between 2015 and 2017.

Results : Pancreatic cancer cells exhibited high N/C ratios with irregular nuclei and prominent nucleoli in all the preparations. The morphometric image analysis of the 30 pancreatic cancer cases showed that the nuclear area of the tumor cells was significantly smaller in the SP-LBC preparations than in the ROSE and Pap. smears (p<0.001). However, there were no significant differences in the nucleus aspect ratio (maximum length/breadth ratio) among the cytology preparations (p=0.291). Furthermore, the number of tumor cells was significantly higher in the SP-LBC preparations than in the ROSE smears (p<0.001). The results of the retrospective review of the 166 pancreatic lesions suggested that the diagnostic accuracy of SP-LBC was higher than that of the squash preparation smears (p<0.001).

Conclusion : Although the nuclear area of the tumor cells differed depending upon the processing method used for cytologic examination (squash and SP-LBC preparations), the number of tumor cells in the preparation and the diagnostic accuracy of SP-LBC were significantly greater than those for the squash preparation smears. Combined diagnostic use of squash preparations and SP-LBC is expected to be effective in reducing the false-negative diagnosis rate of EUS-FNA.

Background : Bilateral breast sarcomas are rare malignancies of unknown etiology. The most commonly reported histological subtypes of breast sarcoma are angiosarcoma, fibrosarcoma, and undifferentiated pleomorphic sarcoma. Furthermore, phyllodes tumors show a propensity for sarcomatous transformation. We report a case of bilateral malignant breast tumors containing pleomorphic liposarcoma components.

Case : A woman in her 30 s presented to another hospital with a 4-month history of rapid enlargement of both breasts. CT revealed a large low-density mass in each of the breasts and multiple nodules in the lungs and bone. Both breasts had swelled to the size of a handball, and contained readily movable elastic lumps. Phyllodes tumor was suspected, and fine-needle aspiration and core needle biopsy were performed. Fine-needle aspiration showed a large number of scattered solitary atypical cells containing spindle-shaped, oval, or bizarre nuclei. The nuclei of the atypical cells varied in size as well as form. The nuclei contained dense granular chromatin and some contained conspicuous nucleoli. Sudan IV staining revealed lipid droplets in the endoplasmic reticulum of the cells. Biopsy specimens obtained from the lesions in both breasts revealed features of pleomorphic sarcoma. There were numerous lipoblasts. There was no evidence of phyllodes tumor or ductal carcinoma components in the specimens. Primary liposarcoma, malignant phyllodes tumor with liposarcomatous differentiation, and metaplastic carcinoma with liposarcomatous differentiation were considered for the differential diagnosis.

Conclusion : We encountered a rare case of bilateral malignant breast tumors containing pleomorphic liposarcoma components.

Background : Pleomorphic adenoma, a common tumor of the salivary glands, is rarely found in the breast. Herein, we report a case of pleomorphic adenoma of the breast which was difficult to diagnose by fine needle aspiration cytology (FNA) alone.

Case : A woman in her 80 s visited our medical center after she noticed a mass in the left breast. A mucocele-like tumor or mucinous carcinoma was suspected from the findings of FNA, and excisional biopsy was performed to obtain a definitive diagnosis. Imprint cytology of the mass showed a large quantity of metachromatic mucin, epithelial cells, and various myoepithelial cells. There were myoepithelial cells that were contiguous with mesenchymal elements. Histopathology revealed myoepithelial cells contiguous with cartilage elements.

Conclusion : The possibility of pleomorphic adenoma of the breast should be borne in mind when cytology reveals a large quantity of metachromatic mucin, epithelial cells, and obtained from mammary gland myoepithelial cells.

Background : Liposarcomas of the spermatic cord are rare, and cytodiagnosis of this tumor can be challenging.

Case : A 71-year-old man visited our hospital with a painless swelling of the left scrotum. Under the suspicion of a paratesticular tumor, a high orchiectomy was performed. Macroscopically, we found a well-defined solid tumor in the spermatic cord, the cut-surface of which was whitish-yellow in color, with patchy areas of necrosis. Touch imprint smears of the tumor showed large, atypical cells arranged in loose sheets or dispersed individually, a substantial number of which contained bizarre multi-lobulated nuclei. Interestingly these atypical cells were surrounded by a large number of small lymphocytes, labelled as tumor-infiltrating lymphocytes (TILs). There were no atypical lipoblasts with multi-vacuolated cytoplasm. Immunohistochemistry and fluorescent in situ hybridization (FISH) of the surgical specimen showed MDM2 overexpression and amplification of the MDM2 gene locus (12q13-15), respectively. The findings suggested the diagnosis of dedifferentiated liposarcoma arising from the spermatic cord.

Conclusion : We report the interesting cytological features in a case of dedifferentiated liposarcoma with dense TIL infiltration ; this evidence of a tumor immune response might be suggestive of a better prognosis.

Background : Invasive lobular carcinoma (ILC) is classified as a special type of breast cancer and accounts for about 5% of all breast cancers in Japan. ILC often produces intracytoplasmic mucin, with the formation of intracytoplasmic lumina and signet-ring cells, but does not harbor extracellular mucin. Herein, we report an extremely rare case of ILC with extracellular mucin.

Case : A woman in her late 50s was detected as having a hypoechoic mass in the left breast measuring 10 mm in diameter. Fine-needle aspiration cytology showed atypical cell clusters with intracytoplasmic mucin and mucous globular-like structures, suggesting that the tumor was malignant. She underwent partial mastectomy, and histopathology showed a tumor composed of classical ILC and mucinous carcinoma-like components with extracellular mucin. Immunostaining for E-cadherin yielded a negative result, not only in the classical ILC component, but also in the mucinous carcinoma-like components ; we diagnosed the tumor as an ILC with extracellular mucin.

Conclusion : Extracellular mucin production is generally associated with tumors of ductal origin ; thus, it was difficult to diagnose the tumor as an ILC from the cell clusters obtained from the mucous nodules. Immunostaining for E-cadherin and catenins is useful for the diagnosis of ILC with extracellular mucin.

Background : We succeeded in detecting recurrence of cervical adenosquamous carcinoma with sarcomatous change by immunocytochemistry (ICC) of liquid-based cytology (LBC) specimens using the cell transfer technique. We report this case with the cytologic findings.

Case : A female patient in her 60 s who was diagnosed as having adenosquamous carcinoma (stage ⅡB, pT2bN0M0) with sarcomatous change by histopathological examination of her hysterectomy specimen. LBC screening of the vaginal stump performed 22 months after the hysterectomy revealed the presence of sarcomatous cells, including spindle-shaped and polygonal cells. Although neither dyskeratotic cells nor obvious adenocarcinomatous features were observed, some multinucleated giant cells were identified. We performed ICC of the LBC specimens using the cell transfer technique and the sarcomatous component showed positive results of staining for cytokeratin (8/18) and p16/ki-67 dual staining. Based on these findings, it was judged that the patient had recurrence of cervical cancer. Consistent with this judgment, a biopsy of the vaginal stump revealed proliferative sarcomatous spindle-shaped cells, confirming the diagnosis of recurrence of cervical cancer.

Conclusions : We succeeded in detecting recurrence of cancer in a patient with non-keratinizing squamous cell carcinoma with sarcomatous change, by ICC of surplus LBC samples using the cell transfer technique. The LBC was also useful for vaginal stump smear testing.

Background : Langerhans cell sarcoma (LCS) is an extremely rare tumor.

Case : A Japanese man in his 50’s presented to us with a swelling in his right upper arm. Four months after the patient first noticed the swelling, he also noticed a swelling in the right axillary region and was referred to our hospital. Needle biopsy of the subcutaneous tumor in the right upper arm proved non-diagnostic. Then, open biopsy was performed. Squash cytology at the open biopsy revealed numerous atypical cells of various sizes, with foamy, lacy cytoplasm. The atypical cells had grooved nuclei and prominent nucleoli. Multinucleated giant cells and mitoses were frequently observed. Cytologically, Langerhans cell tumor was suspected. Histologically, the open biopsy specimen revealed a diffuse growth of large, pleomorphic cells with a moderate amount of cytoplasm. The tumor cells had vesicular nuclei with irregular contours, and prominent nucleoli. Multinucleated cells or giant cells were also found. Mitoses were frequently observed. Together with the clinical information, the tumor was diagnosed as a LCS.

Conclusion : In the differential diagnosis of LCS, the following cytological features favor a diagnosis of LCS : 1. Neoplastic cells with overtly malignant features - especially, prominent nucleoli, multinucleated giant cells, and frequent mitotic figures ; 2. Scant eosinophils in the background.

Background : We report a case of uterine corpus cancer containing atypical high-grade component showing loss of expression of the switch/sucrose-nonfermenting (SWI/SNF) complex, with a review of the literature.

Case : A female in her 50 s was admitted to our Department of Obstetrics and Gynecology for positive endometrial cytology. We reviewed the endometrial cytology findings and confirmed the following characteristics : a high nuclear-to-cytoplasmic ratio, 3-dimensional groups of cells, including papilliform structures, and fragments of fibrovascular cores with atypical cells. Imaging examinations and endometrial curettage revealed type Ⅱ carcinoma of the lower uterine segment and radical operation was performed. Gross examination revealed a mass in the lower uterine segment measuring 4 cm in diameter. The tumor was judged as a Grade 1 endometrioid carcinoma and a high-grade carcinoma with a micropapillary pattern ; the transition was abrupt. Immunohistochemically, the Grade 1 endometrioid carcinoma showed positive staining for ER, PAX8, BRG1, and BRM, whereas the high-grade component showed negative staining for all of the above.

Conclusion : There possibly exist differentiated endometrial cancers harboring SMARCA4/SMARCA2 defect, such as dedifferentiated/undifferentiated carcinomas. Such tumors can be diagnosed from the aforementioned cytological findings.