Cervical cancer screening rates in Japan are quite low compared to other developed countries. The majority of women diagnosed with uterine cervical cancer belong to the younger, employed generation. There are three modes of cancer screening in Japan : “Population-based screening”, “Screening in the Workplace”, and “Opportunistic screening”. Uterine cervical cancer screenings are not typically included in mandatory work place physical health checkup examinations, and inclusion is dependent on the policy of the employer. Between 30 to 60% of uterine cervical cancer screenings are conducted at occupational health checks, but many companies maintain no detailed information about examination results. The “Manual of Cancer Screening in the Workplace,” established by the Japan Ministry of Health, Labor and Welfare in March, 2018, recommends that Pap test results should be monitored as a “Population-based screening” mechanism. Uterine cervical cancer screening by employers is now increasingly important, based on the growth of the female work place population. Although it may be a significant increase in personal data management, occupational physicians and health care nurses should oversee female health education and Pap test result monitoring.

Indeed, the increasing cervical cancer incidence and mortality among young women in Japan is a critical consideration.

Objective : In this study, we analyzed the distribution and number of tumor cells (TC) in different sections of the cell sediment prepared by the test tube method (vertical split section (VSS) vs. horizontal cross section (HCS)).

Study Design : We prepared nucleated cell sediment layers (VSS and HCS) by the test tube method from 87 pleural fluid samples. We classified the VSS into three layers (A, B, and C) to evaluate the distribution of TC, and counted the TC in the HCS and each layer of the VSS. Based on the findings, we classified the samples into two groups : TC-high (TC-H) and TC-low (TC-L).

Results : The 87 samples were classified into 57 TC-H cases and 30 TC-L cases based on examination of the VSS, and into 47 TC-H cases and 40 TC-L cases based on examination of the HCS. In the 57 VSS/TC-H cases, we found uneven distribution of the TC in the three layers in 15 samples. Interestingly, in a proportion of HCS/TC-L cases (9 samples), TC was found only on examination of the VSS, but not on examination of the HCS.

Conclusion : Our results showed that examination of VSS specimens prepared by the test tube method might be more useful for evaluating the amount and distribution of TC in a cell block sample.

Objective : We investigated a novel screening method for lobular endocervical glandular hyperplasia (LEGH) in patients with abnormal mucin color, as identified by cervical and endometrial liquid-based cytology (LBC).

Study Design : We examined the feasibility of LEGH screening by adding alcian blue (pH2.5)/D-periodic acid-Schiff stain (AB/PAS) to LBC in 20 cases of cervical and/or endometrial cytology with the two-color pattern or yellowish mucin. The HIK1083-labeled latex agglutination test (HIK test) was used to confirm gastric mucin.

Results : In 3 of the 20 cases, yellowish mucous cells were observed in both cervical and endometrial LBC ; in 8 cases, these cells were only found in endometrial LBC. In all 20 cases, AB/PAS confirmed neutral mucous cells that showed a reaction only to PAS. The HIK test was positive in 18 cases.

Conclusion : Background mucin disappears in LBC, and cytoplasmic mucin reflects the color of the cell’s mucous itself, similar to the case in histology, thereby enabling the use of AB/PAS, which can otherwise not be used with smears due to overlap with the background mucins. This makes it possible to identify gastric-type neutral mucins in LBC and contributes to screening for LEGH.

Background : We report the cytologic findings in a case of the sporadic cribriform-morular variant of papillary thyroid cancer (CMV-PTC), findings that may be associated with its biological characteristics.

Case : A woman in the third decade of life came to our hospital with a chief complaint of an approximately 5-cm mass in the right lobe of her thyroid gland. Smears of aspirated thyroid tissue revealed a variable architectural pattern. The epithelial cells were arranged in stratified papillae, cribriform clusters, and monolayer sheets, some of which displayed cellular discohesion and spindling at the borders. Ovoid nuclei were characterized by coarse chromatin distribution, indistinct nucleoli, nuclear grooves, and a few cytoplasmic inclusions. We initially diagnosed the lesion as a PTC, but subsequent histological examination led to a final diagnosis of CMV-PTC. Review of the cytological smears revealed that some of the clusters lacked sharp anatomical borders or nuclear palisading. Individual cell morphology ranged from polygonal, tall columnar to fusiform. Immunochemistry revealed marked β-catenin accumulation in the nucleus and the cytoplasm of the tumor cells, whereas there was as decreased amount or no β-catenin in its normal membranous location.

Conclusion : The cell junctions at the edges of the clusters of CMV-PTC cells were loose, and solitary cells were conspicuous. We concluded that the weakened cell adhesion together with the intranuclear accumulation of β-catenin caused by the abnormal activation of the Wnt signaling pathway affect the cytological characteristics of CMV-PTCs.

Background : Ovarian clear cell carcinoma is characterized by glycogen accumulation in the cytoplasm. However, to the best of our knowledge, there has never been a report of intranuclear inclusion bodies resulting from glycogen accumulation in ovarian clear cell carcinoma.

Case : We report a rare case of a 6X-year-old female who initially presented with lower left quadrant abdominal pain. She was referred to our hospital for further consultation, because a malignant pelvic mass (diameter, ～20 cm) was suspected, and she was diagnosed with a malignant epithelial tumor of the ovary. A cytology specimen was prepared by imprinting a fresh tumor slice at the time of intraoperative rapid diagnosis. The cytology specimen showed atypical cells with enlarged nuclei and nucleoli. The cytoplasm was light green and pale, and the white and bright nuclei contained inclusion-like bodies. The inclusion-like bodies showed a positive periodic acid-Schiff-positive reaction that became negative after diastase digestion, suggesting the presence of glycogen. The histological specimen contained a conspicuous area of glycogen intranuclear inclusion bodies. The final histopathological diagnosis was ovarian clear cell carcinoma.

Conclusion : This is a valuable case of glycogen intranuclear inclusion bodies in an ovarian clear cell carcinoma.

Background : The cytomorphology of adenomyoepithelioma (AME) with carcinoma has never been adequately assessed. We describe the features of this rare neoplasm as revealed by fine-needle aspiration biopsy.

Case : The patient, was a woman in her 70 s, who discovered a lump in her right breast during self-examination. Imaging demonstrated a solid nodule (measuring 2.2 cm) in the lower outer quadrant of the right breast. Fine-needle aspiration revealed moderate to large clusters of epithelial and myoepithelial cells containing 3-dimensional papillotubular structures. In the background, there were densely distributed discohesive myoepithelial cells containing naked nuclei or pale cytoplasm, often exhibiting intracytoplasmic vacuoles and nuclear atypia. A metachromatic stroma often accompanied the clusters or was present in the form of droplets in the background. Histologically, the resected tumor showed microinvasion by atypical myoepithelial cells, and we made the diagnosis of AME with carcinoma.

Conclusion : The cytodiagnosis of AME is based on the identification of large clusters of cells composed of two populations, and they sometimes contain 3-dimensional papillotubular structures. The presence of myoepithelial cells having a vacuolar cytoplasm, that are either dispersed or arranged in small clusters, together with a metachromatic stroma, may be useful in making the diagnosis of AME.

Background : Lymphangioleiomyomatosis (LAM) is a systemic disease characterized by proliferation of smooth muscle-like tumor cells in the lungs and axial lymph nodes. It is a rather rare disease, and no effective treatment has been established yet. Herein, we report a case of LAM diagnosed by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA).

Case : A woman in her 50 s was found to have high serum CA19-9 levels and multiple lymphadenopathy around the abdominal aorta. She had no significant past medical history or respiratory symptoms. EUS-FNA of the affected lymph nodes was performed under the suspicion of lymph node metastasis, and cytological examination revealed a strongly bound cluster of spindle-shaped cells arranged in fascicles. The cells had oval-to-spindle-shaped nuclei with fine granular chromatin and intranuclear cytoplasmic inclusion bodies. Histological examination of biopsy specimens revealed similar findings. Therefore, we report this case in which the diagnosis of LAM was confirmed by immunohistochemical analysis.

Conclusion : To establish the diagnosis of LAM from cell findings other than LAM cell clusters in fluid samples from chylothorax, more case reports, confirmation of clinical findings and detailed cell observation, and comparison with the features of diseases included in the differential diagnosis are necessary. Immunocytochemical staining may be also important.

Background : Perivascular epithelioid cell tumor (PEComa) is a rare mesenchymal neoplasm. Herein, we report two cases of gynecologic PEComa with different clinical features and outcomes.

Cases : Case 1 (woman in her 10 s) : contrast-enhanced computed tomography (CT) and magnetic resonance imaging revealed a pelvic solid tumor and ascites. Open biopsy and touch imprint cytology of the pelvic tumor and cytology of the ascites were performed. Case 2 (woman in her 60 s) : She presented with atypical genital bleeding, and endometrial cytology and biopsy were performed. Cytologically, both cases showed proliferating tumor cells scattered or arranged in loose clusters, with thin-walled blood vessels at the core. The tumor cells showed abundant clear or eosinophilic cytoplasm, prominent nucleoli, and intranuclear pseudoinclusions. There were differences in the degree of cytomorphologic atypia and dyskaryosis between the two cases. Histologically, proliferating tumor cells having clear cytoplasm were seen, arranged in sheets and/or a papillary pattern, with a thin-walled vascular core. Immunohistochemically, both tumors were positive for HMB-45 and Melan A, and based on the findings, we made the diagnosis of PEComa in both patients. Case 1 died of tumor progression one year after the diagnosis, whereas case 2 survives, with stable disease, 3 years after the diagnosis.

Conclusion : PEComa can arise in various organs, and can be encountered in all kinds of specimens. When a tumor is composed of cells with clear cytoplasm suggestive of PEComa, immunohistochemistry will be useful for the diagnosis.

Background : Primary effusion lymphoma (PEL) is a large B-cell neoplasm usually manifesting as serous effusions without any detectable tumor masses. It is associated with human herpesvirus 8 (HHV8), also called Kaposi sarcoma-associated herpesvirus. The prognosis is extremely unfavorable. On the other hand, a PEL-like condition in the absence of HHV8 infection showing a spontaneous regression has also been reported. PEL-like lesions, as a group, are usually referred to as a HHV8-negative PEL-like lymphoma.

Case : The patient was a man in his 70 s, who presented with shortness of the breath. Ultrasonography revealed marked pericardial effusion. Cytology of the pericardial fluid showed numerous atypical large lymphocytes, highly suggestive of a large-cell lymphoma. However, the clinical symptoms improved dramatically after pericardial fluid drainage, and the patient, who is under close follow-up, remains alive, without recurrence. Based on the above-mentioned clinical course and negative test result for HHV8, we strongly suspect that the correct diagnosis is PEL-like lymphoma.

Conclusion : To avoid excessive treatment, it is necessary to differentiate between PEL and PEL-like lymphoma by the presence or absence of HHV8 infection.

Background : Primary effusion lymphoma (PEL) is a rare B-cell lymphoma that most often occurs in patients with human immunodeficiency virus (HIV) infection. Herein, we report a case of PEL in an HIV-negative patient.

Case : A 68-year-old man, living in Miyako islands of Okinawa prefecture, presented to a previous hospital with a history of dyspnea and right lumbar pain. CT revealed right pleural effusion, and the findings of pleural fluid cytology led to the suspicion of malignant lymphoma. The patient was then referred to and admitted at our hospital. Cytology repeated at our hospital showed large atypical cells with severe nuclear atypia. Immunohistochemical analysis of a cell-block specimen showed positive staining of the cells for CD30 and LANA-1, and negative staining for CD20. As no other tumor lesion was found on further work-up, we made the diagnosis of PEL. HIV antigen-antibody testing returned negative results.

Conclusion : PEL most often occurs in immunocompromised patients with HIV infection, and seldom in HIV-negative patients. Cases of PEL in immunocompetent elderly patients have been reported from geographical areas with a high prevalence of human herpesvirus type-8 (HHV8) infection, such as the Mediterranean region. Miyako islands, in Okinawa prefecture, are also known for a high prevalence of HHV8 infection. Hence, especially in patients from these areas, the possibility of PEL should be borne in mind when body fluid cytology in HIV-negative elderly individuals reveals large atypical lymphocytes.