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Our objective was to determine whether the Toyota Production System process redesign resulted in diagnostic error reduction for patients who underwent cytologic evaluation of thyroid nodules. In this longitudinal, nonconcurrent cohort study, we compared the diagnostic error frequency of a thyroid aspiration service before and after implementation of error reduction initiatives consisting of adoption of a standardized diagnostic terminology scheme and an immediate interpretation service. A total of 2,424 patients underwent aspiration. Following terminology standardization, the false-negative rate decreased from 41.8% to 19.1% (P = .006), the specimen nondiagnostic rate increased from 5.8% to 19.8% (P < .001), and the sensitivity increased from 70.2% to 90.6% (P < .001). Cases with an immediate interpretation had a lower noninterpretable specimen rate than those without immediate interpretation (P < .001). Toyota process change led to significantly fewer diagnostic errors for patients who underwent thyroid fine-needle aspiration.

Scant published data exist on redesigning pathology practice based on error data. In this first step of an Agency for Healthcare Research and Quality patient safety project, we measured the performance metrics of thyroid gland fine-needle aspiration, performed root cause analysis to determine the causes of error, and proposed error-reduction initiatives to address specific errors. Eleven cytologists signed out 1,543 thyroid gland aspirates in 2 years, and surgical pathology follow-up was obtained in 364 patients. Of the 364 patients, 91 (25.0%) had a false-negative diagnosis and 36 (9.9%) a false-positive diagnosis. Root cause analysis showed that major sources of error were pre-analytic (poor specimen quality) and analytic (interpretation of unsatisfactory specimens as nonneoplastic and lack of diagnostic category standardization). We currently are evaluating the effectiveness of error reduction initiatives that target pre-analytic and analytic portions of the diagnostic pathway.

Background Adult perineal soft tissue sarcomas are rare. Fewer than 30 cases have been reported, and all were diagnosed after surgical resection by histologic examination. Below we report a case in which the diagnosis was established preoperatively by fine needle aspiration (FNA). Case A 27-year-old man presented with a firm, midline, perineal mass. Magnetic resonance imaging showed a 3-cm, enhancing mass that was considered neoplastic. FNA biopsy, followed by cytologic examination, revealed moderately cellular aspirates composed of discohesive, small, blue cells with scant cytoplasm, high nuclear/cytoplasmic ratios and pleomorphic nuclei with irregular nuclear contours; uniform, hyperchromatic chromatin; and occasional mitotic figures. Frequent naked nuclei and scattered cells with more abundant, dense cytoplasm and eccentric nuclei were also noted. The diagnosis of rhahdomyosarconia was favored on FNA and was corroborated by immunohistochemical stains for desmin, myogenin and CD 56. Upon surgical resection, the diagnosis of alveolar rhabdomyosarcoma was confirmed histologically and immunophenotypically. Conclusion FNA is a useful tool in diagnosing soft tissue lesions of the perineum, including rare primary tumors, such as adult rhabdomyosarcoma. In this case, early identification avoided incisional biopsy and directed appropriate extirpative surgery and reconstruction considerations.

Nocardia is an uncommon pathogen in immunocompetent patients; however, it has been increasingly recognized as a significant opportunistic pathogen in organ transplant patients. Diagnosis of Nocardiosis is usually made by microbiologic culture or cytologic examination of pulmonary specimens including, sputum, and brushing/washings or by histologic evaluation of tissue biopsy material. We report a case of subcutaneous Nocardiosis diagnosed by Fine-needle aspiration biopsy (FNA). The patient is a 66-year-old man with a history of lung transplantation and posttransplant lymphoproliferative disorder who presented with subcutaneous masses in the right upper arm and the left shoulder. FNA was performed in an outpatient clinic setting, with immediate morphologic assessment revealing filamentous branching organisms suspicious for Nocardiosis. Subsequent examination with special stains and microbiologic culture confirmed the diagnosis. The quick and accurate diagnosis by FNA led to emergent and appropriate treatment.

BACKGROUND. Various research groups have attempted to grow fresh, histologically intact human prostate cancer tissues in immunodeficient mice. Unfortunately, grafting of such tissues to the sub-cutaneous compartment was found to be associated with low engraftment rates. Furthermore, xenografts could only be established using high-grade, advanced stage, but not low- or moderate-grade prostate cancer tissues. METHODS. This paper describes methods for xenografting both benign and malignant human prostate tissue to severe combined immunodeficient (SCID) mice. We examine the efficiency and histopathologic consequences of grafting to the sub-cutaneous, sub-renal capsule, and prostatic orthotopic sites. RESULTS. Sub-renal capsule grafting was most efficient in terms of take rate (>90%) for both benign and malignant tissue. Orthotopic grafts consistently exhibited the best histopathologic differentiation, although good differentiation with continued expression of androgen receptors (AR) and PSA was also seen in the sub-renal capsule site. Sub-cutaneous grafting resulted in low take rates and the lowest level of histodifferentiation in surviving grafts. Grafted benign tissues in all sites appropriately expressed AR, PSA, cytokeratins 8, 18, and 14 as well as p63; carcinoma tissues did not express the basal cell markers. Grafting of tissues to castrated hosts did not affect

Background The protean morphology of malignant melanoma is diagnostically challenging. Balloon cell melanoma is a histologic variant composed predominantly or entirely of large cells with abundant, vacuolated cytoplasm. It shares the cytologic features of the other subcategories of malignant melanoma, such as discohesion, nuclear pleomorphism and intranuclear cytoplasmic pseudoinclusions, but generally lacks melanin pigment and, as the name would suggest, is characterized by the presence of numerous cytoplasmic vacuoles. Case A 55-year-old man presented with an enlarged right cervical lymph node. Clinically and radiographically this mass was considered to be metastatic; however, the patient had no known primary neoplasm. Fine needle aspiration biopsy (FNAB) and cytologic examination showed numerous discohesive, variably sized, malignant cells with abundant, vacuolated cytoplasm and pleomorphic nuclei with irregular nuclear contours, macronucleoli and frequent intranuclear cytoplasmic pseudoinclusions. Pigment was not identified. These features, along with strong immunohistochemical positivity for S-100, HMB-45 and Melan-A, suggested the diagnosis of balloon cell melanoma. A right parotidectomy and lymph node dissection were performed, and histologic tissue evaluation confirmed the diagnosis. Conclusion This case of lymph node balloon cell melanoma metastasis was diagnosed by FNAB.

BACKGROUND: Epithelioid hemangioma (EH) is an uncommon, benign, vascular lesion of unknown etiology. The clinical differential diagnosis is broad and includes both epithelial and vascular neoplasms. In contrast to the histopathology of this lesion, the cytopathology, as obtained by fine needle aspiration biopsy (FNAB), has been described only once before. CASES: Two cases of EH of the oral cavity were evaluated by FNAB. The first case included histologic follow-up, while the second included immunohistochemical analysis of the aspirate material (cell block). The smear characteristics included cohesive epithelioid cells with moderate cytoplasm, ovoid nuclei and small nucleoli that formed occasional abortive vascular channels as well as spindle cell groups and a few larger cells with pleomorphic nuclei and irregular nuclear contours against a largely bloody background. Immunohistochemical staining for CD34 and factor VIII-related antigen confirmed the endothelial nature of these proliferations. CONCLUSION: The cytomorphology, an endothelial immunophenotype, and the appropriate clinical presentation should permit diagnostic consideration of EH in the differential diagnosis of an endothelial lesion.

The incidence of human epidermal growth factor receptor 2 (HER2) protein overexpression and its prognostic value are not well characterized in patients with prostate cancer. A phase I study was designed to evaluate docetaxel/estramustine plus trastuzumab, a humanized monoclonal antibody that binds to the HER2 receptor, in patients with metastatic androgen-independent prostate cancer (AIPC). HER2 positivity was not required because safety was the primary endpoint. Patients received oral estramustine 280 mg three times daily (days 1 to 5); docetaxel, 70 mg/m 2 intravenously (day 2); and trastuzumab, 2 mg/kg intravenously (days 2, 9, and 19), every 21 days until the disease progressed or toxicity became unacceptable. This regimen was well tolerated among the first 13 treated patients. Grade 4 neutropenia was seen in 10% of administered cycles. There were two episodes of febrile neutropenia and two thrombembolic events. Of the 13 patients evaluable for prostate-specific antigen (PSA) response, nine (69%) experienced a decrease in PSA level of >50%. Two (33%) of six patients with measurable disease had objective responses, and one complete response was seen on bone scan. Docetaxel/estramustine/trastuzumab appears to be a safe combination when used in the treatment of metastatic AIPC. The response data are too preliminary for speculation about the relative benefits of this 3-drug regimen compared with the combination of only docetaxel and estramustine in this clinical setting.

BACKGROUND: Metastatic malignancy involving the ocular uveal tract is rare, Approximately one-third of patients will present without a known primary site. This is the ninth reported clinically detected case of ovarian carcinoma metastatic to the eye, the second with mucinous differentiation and the first in which the diagnosis was established by fine needle aspiration (FNA), CASE: A woman developed ovarian mucinous adenocarcinoma metastatic to the choroid layer of the eye. CONCLUSION: FNA is useful in diagnosing lesions of the eye and orbit, including diagnosis of rare metastatic lesions.

BACKGROUND The prognostic values of intratumoral microvessel density (iMVD), tumor cell proliferation rate, DNA content (ploidy), and p53 protein expression are controversial or have not been well studied in patients with renal cell carcinoma (RCC) confined to the kidney. METHODS A uniform group of 52 clear cell (conventional) RCCs confined to the kidney (classified as T1N0M0 or T2N0M0) were analyzed for iMVD, MIB-1 score, DNA content, S-phase fraction, and p53 protein expression by immunohistochemical methods or flow cytometry. iMVD was evaluated in a single area (X200, 1.15 mm2) representative of the highest MVD (neovascular "hot spot") after independently highlighting endothelial cells with antibodies specific for factor VIII-related antigen (F8/86) and CD31 (JC/70A). The MIB-1 antibody (Ki-67 antigen) score was used as a marker for the tumor cell proliferation rate. DNA content and S-phase fraction were determined by flow cytometry using paraffin embedded tissue. p53 expression was assessed using the D07 antibody. RESULTS The median time of clinical follow-up was > 9 years. Eleven patients died of disease; the median time to death was 26 months. iMVD counts using antifactor VIII and anti-CD31 were tightly correlated (correlation coefficient = 0.89). S-phase fraction was higher in aneuploid tumors than in diploid tumors (mean, 12.4% vs. 4.3%; P = 0.01). Using univariate survival analyses, tumor size (stage classification pT1 vs. PT2; P = 0.01) and nuclear grade (P = 0.04) were associated with shortened survival. No statistically significant differences in survival were found for iMVD, MIB-1 score, DNA content, S-phase fraction, or p53 expression. Only two cases strongly expressed p53 protein; both tumors were of high nuclear grade. Using multivariate survival analyses, nuclear grade and tumor size were the only independent prognostic factors (best model P = 0.002). CONCLUSIONS In this study, nuclear grade and tumor size were found to be independent predictors of survival in locally confined clear cell (conventional) RCC, as has been shown previously for locally confined RCC in general. MIB-1 score, iMVD counts, DNA content, S-phase fraction, and p53 expression did not contribute additional prognostic information. Cancer 1997; 80:1768-75. © 1997 American Cancer Society.

Intracortical osteosarcoma is the rarest form of osteosarcoma and typically occurs in the young. The authors describe a case of intracortical osteosarcoma arising in the femur of a 44-year-old woman. A diaphyseal location and a typical radiographic appearance, illustrated in this report, distinguish intracortical osteosarcoma from conventional (intramedullary) osteosarcoma, but not from less common forms of osteosarcoma or from several benign bone tumors. This case illustrates the low-grade osteoblastic histology, malignant osteoid formation, and medullary and surrounding soft tissue invasion diagnostic of intracortical osteosarcoma. The authors discuss the diagnostic difficulties presented by intracortical osteosarcoma and the natural history of these tumors. Int.J Surg Pathol 3(3):195-200, 1996

Detailed root cause analysis to determine causes of pulmonary cytology errors has not been used to design specific practice changes. We performed root cause analysis of all false-negative bronchial brushing and washing specimen errors (n = 32) detected by the cytologic-histologic correlation process in 2002. Medical records and all slides were reviewed. Based on the correlation process, 10 errors were interpretive, 16 sampling, and 6 combined interpretive/sampling. Root cause analysis showed that the lesion was not accessible in 8 cases and tumor was readily identified on the slides in only 1 case. In 11 cases, the malignant cells were few and not recognized, and in 13 cases, obscuring artifacts (eg, cellular crushing and air drying) limited interpretation. Sampling issues had a major role in the misdiagnosis in 31 cases (97%), and recommendations for error reduction include immediate interpretation and the use of transmucosal fine-needle aspiration.

Because of the paucity of available tissue, little information has previously been available regarding the gene expression profiles of primary melanomas. To understand the molecular basis of melanoma progression, we compared the gene expression profiles of a series of nevi, primary melanomas, and melanoma metastases. We found that metastatic melanomas exhibit two dichotomous patterns of gene expression, which unexpectedly reflect gene expression differences already apparent in comparing laser-capture microdissected radial and vertical phases of a large primary melanoma. Unsupervised hierarchical clustering accurately separated nevi and primary melanomas. Multiclass significance analysis of microarrays comparing normal skin, nevi, primary melanomas, and the two types of metastatic melanoma identified 2,602 transcripts that significantly correlated with sample class. These results suggest that melanoma pathogenesis can be understood as a series of distinct molecular events. The gene expression signatures identified here provide the basis for developing new diagnostics and targeting therapies for patients with malignant melanoma.

Objectives. To report our experience with intraoperative frozen section (IFS) analysis in patients who are potential candidates for nerve-sparing surgery. Potency can be maintained in select patients who undergo radical prostatectomy using a nerve-sparing approach. However, extracapsular disease extension in the area of the neurovascular bundles may compromise adequate surgical margins in some patients undergoing such surgery. Methods. We reviewed the pathologic results from 101 patients who underwent either unilateral or bilateral nerve-sparing radical prostatectomy in whom IFS analysis was performed. The clinical disease stage was T1 in 20 patients and T2 in 81 patients. The mean serum prostate-specific antigen level before surgery was 7.2 ng/mL. Of the 101 patients, 62, 28, and 11 had a biopsy Gleason score of 2 to 6, 7, and 8 to 10, respectively. IFS analysis was performed on the surgical margin thought to be at risk of tumor involvement as determined by the results of systematic prostate biopsy, transrectal ultrasonography, or intraoperative inspection. If the frozen section was positive, additional tissue, including the neurovascular bundle, was subsequently removed to establish clear surgical margins. IFS results were compared with those on the final, permanent tissue section, as well as with the status of the additionally resected tissue. Results. The IFS results were identical to those obtained on the final, permanent section in 92 (91%) of the 101 cases. The IFS results showed positive margins in 15 (15%) of 101 patients. Of these cases, 11 demonstrated positive margins on the final permanent sections. Of the 86 patients with negative frozen section diagnosis, 5 had positive surgical margins on permanent sections at the site of the IFS. The positive and negative predictive value for the IFS technique was 73% and 94%, respectively. Of the 15 patients with positive IFS, 12 (80%) had no evidence of tumor in the additionally resected tissue. Prostate-specific antigen recurrence was noted in 7% of the study population. The risk of recurrence in patients with either positive or negative IFS findings was similar. Conclusions. IFS at the time of radical prostatectomy can reliably predict the final surgical margin status in most carefully selected high-risk patients when there are concerns about the margin status.

The role of the HER2 receptor remains uncertain in the pathogenesis and progression of human prostate cancer. Previous studies have reported widely divergent rates for HER2 expression in primary prostate tumors, probably owing to significant methodologic differences in the studies. Few data exist about the frequency of HER2 protein overexpression and gene amplification in androgen-independent prostate cancer (AIPC), although recent xenograft models suggest HER2 expression may be up-regulated in the transition from androgen-dependent to androgen-independent disease. We studied the role of HER2 protein in AIPC by immunohistochemical and fluorescence in situ hybridization (FISH) analyses on AIPC specimens using well-characterized and validated reagents. Fourteen (36%) of 39 specimens expressed HER2; however, only 2 (5%) had moderate (2+) expression, and 2 (5%) had high-level (3+) expression. Two (6%) of 36 specimens had gene amplification by FISH. These data suggest that HER2 protein overexpression and gene amplification are relatively uncommon in AIPC.

Calcifying aponeurotic fibroma is a rare benign soft tissue proliferation, which occurs in the distal extremities in children. We describe a case of calcifying aponeurotic fibroma of the hand in a 9 year-old male diagnosed by FNA. Clinically and radiographically this mass was felt to be suspicious for sarcoma, likely alveolar rhabdomyosarcoma. Cytologic examination revealed benign appearing spindled cells, chondroid cells, multinucleated giant cells and calcific debris. These features recapitulate the classic histologic features of calcifying aponeurotic fibroma. Conservative excision was performed and histologic exam confirmed the diagnosis. To the authors' knowledge, this is the first description of the cytologic features of this entity.

OBJECTIVE: Dermatopathic lymphadenitis (DL) can be a nonneoplastic cause of an enlarged lymph node or nodes. Cytologic findings of DL have not bee well described. The differential diagnosis includes Langerhans nosis includes Langerhans histiocytosis (LH) in children and low grade lymphoma in adults. We present three cases of dermatopathic lymphadenitis with a discussion of cytologic findings and differential diagnosis. STUDY DESIGN: fine needle aspiration (FNA) findings of three cases of lymph nodes involved by DL were reviewed. All three were axillary lymph nodes in patients with skin rashes. Immunoperoxidase stains for S-100 and CD1a were performed on a cell block from one case, and flow cytometric analysis was performed on another. RESULTS: FNA of DL yields cellular smear with abundant histiocytoid cells with moderate cytoplasm and ovoid, vesicular nuclei with longitudinal grooves (interdigitating reticulum cells). These histiocytoid cells are S-100 and CD1a positive. The background cells are mature lymphocytes, scattered eosinophils and plasma cells. Case 1 was originally misinterpreted as consistent with LH. In case 2, flow cytometric analysis of a mixed population of lymphocytes was seen, ruling out lymphoma. In case 3, the diagnosis of DL was based on morphologic features. CONCLUSION: Interdigitating reticulum cells in dermatopathic lymphadenitis are S-100 and CD1a positive and could be confused with LH in children. In adults, flow cytometry could be used to distinguish them from low grade lymphoma. FNA findings of DL should be interpreted with the clinical history.

Ewing's sarcoma in the infant and young child is rare, highly malignant, and can be difficult to identify. An erroneous diagnosis of osteomyelitis may be considered first because the presentation may be similar to that of Ewing's sarcoma, and routine laboratory evaluation may not distinguish between these entities. Two such cases are presented, one involving the tibia in a 16-month-old child and another a finger phalanx in a 7-month-old child. In both cases the correct diagnosis of Ewing's sarcoma was delayed because of initial misdiagnosis of osteomyelitis. This diagnostic dilemma is summarized, and the literature reviewed. Special attention is given to recent advances in histochemistry and cytogenetics that assist in tumor identification. The conclusion highlights areas of remaining controversies for which additional study may facilitate distinction between osteomyelitis and Ewing's sarcoma.