Zarka, Matthew A.

Background We previously presented that women with chronic rhinosinusitis (CRS) who elected endoscopic sinus surgery (ESS) have a higher symptom burden than men. Causes of these gender-based differences warranted further study. Objectives To study gender differences in another cohort of adult patients with CRS who underwent ESS and to compare key histopathologic and serologic features Methods Patients with CRS who underwent ESS (from 2011 to 2014) with structured histopathology reports on surgical samples were studied. The 13-item structured histopathology report detailed key metrics of inflammation and the presence of fungal elements. Clinical, 22-item Sino-Nasal Outcome Test (SNOT-22) score, Lund-Mackay computed tomography (CT) score, serologic (immunoglobulin E [IgE] level, absolute eosinophil count) and histopathologic data were compared between male and female patients by using statistical software. Results We studied 130 eligible subjects (mean age, 54.7 years; 49.2% women). Compared with the men, the women had significantly higher preoperative SNOT-22 scores (women, 48.7; men 38.0 [p = 0.004]) but similar CT scores. Serum IgE levels were significantly higher among women versus men (peak, 433.3 versus 190.8 kU/L [p = 0.03]; closest to surgery, 435.0 versus 190.8 kU/L [p = 0.03]). Tissue fungal elements were significantly more prevalent in women versus men (19.0 versus 5.2%; p = 0.02). Up to this point, the analysis was agnostic of clinical details of the subjects. Further analysis was conducted regarding clinical features. Allergic fungal sinusitis (AFS) was found significantly more commonly in the female versus male patients (21.9 versus 9.1%; p = 0.04). Women versus men had a higher prevalence of migraine (19.4 versus 4.6%; p = 0.01) or any primary headache disorders (23.0 versus 6.2%; p = 0.007). Conclusion Women who underwent ESS for CRS had higher SNOT-22 symptom burden. Worsened symptomatology may be secondary to a higher prevalence of primary headache disorders in women. However, surgeons should also be aware that female patients with CRS who seek ESS may have a higher prevalence of severe disease endotypes (more tissue fungal elements, elevated serum IgE levels) and phenotypes.

Objective This study sought to estimate the prevalence of median lingual lymph node (MLLN) metastases from oral cavity squamous cell carcinoma (OCSCC) and determine the frequency with which MLLNs can be identified with magnetic resonance imaging (MRI) in control subjects. Methods Pathology reports were used to identify patients with surgically treated OCSCC who underwent preoperative positron emission tomography–computed tomography to define the prevalence of MLLN metastases. As a control group, 500 consecutive face-neck MRIs from noncancer patients were reviewed for structures consistent with MLLNs. Results In the study group, 1 (0.95%) of 105 OCSCC cases demonstrated a single MLLN metastasis from a lateral tongue tumor (T4aN2c). The MLLN exceeded 1 cm in all planes and was abnormal in morphology. The frequency of suspected MLLNs in controls was 1.0%, with a maximum measurement of 0.9 cm. Conclusions Median lingual lymph nodes are infrequently identified with MRI in controls, concordant with the low prevalence of metastases from OCSCC to this inconstant nodal group.

Introduction: The increasing use of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) cytology to examine pancreatic neoplasms has led to an increase in the diagnosis of metastases to the pancreas. Renal cell carcinoma (RCC) is the most common metastasis to the pancreas. Our study examines 33 cases of metastatic RCC to the pancreas sampled by EUS-FNA from four large tertiary care hospitals. Materials and Methods: We searched the cytopathology database for RCC metastatic to the pancreas diagnosed by EUS-FNA from January 2005 to January 2015. Patient age, history of RCC, nephrectomy history, follow-up postnephrectomy, radiological impression, and EUS-FNA cytologic diagnosis were reviewed. Results: Thirty-three patients were identified. The average age was 67.5 years (range, 49–84 years). Thirty-two patients had a previous documented history of RCC. One patient had the diagnosis of pancreatic metastasis at the same time of the kidney biopsy. Thirty-one patients had been treated with nephrectomy. Twenty-seven patients were being monitored annually by computed tomography or magnetic resonance imaging. Twenty-five patients had multiple masses by imaging, but 8 patients had a single mass in the pancreas at the time of EUS-FNA. EUS-FNA of 20 cases showed classic morphology of RCC. Thirteen cases had either “atypical” clinical-radiologic features or morphologic overlaps with primary pancreatic neoplasms or other neoplasms. Cell blocks were made on all 13 cases and immunochemical stains confirmed the diagnosis. Conclusions: EUS-FNA cytology is useful for the diagnosis of metastatic RCC to the pancreas. Cytomorphology can be aided with patient history, imaging analyses, cell blocks, and immunochemical stains.

Purpose: To report the outcomes of patients with favorable risk oropharyngeal cancer that underwent adjuvant radiation therapy with omission of the primary site from the clinical target volume (CTV). Material/Methods: A retrospective study of 40 patients treated with transoral surgery (TOS) followed by neck only radiation using intensity modulated radiation therapy (IMRT) with exclusion of the primary site. For all patients, a CTV of the primary surgical bed was contoured to obtain the estimated incidental dose to the primary site. Results: Median follow-up was 51 months (range, 13-155 months). The median radiation therapy (RT) dose to the neck was 6000 cGy (range, 5400-6400 cGy). The mean incidental dose to the primary tonsillar site was 4320 cGy (SD ± 480 cGy) and to the primary base of tongue site was 4060 cGy (SD ± 420 cGy). There were no local failures and only 1 regional failure, resulting in 97.5% locoregional control rate at 4 years. Two patients developed distant metastases, without evidence of locoregional recurrence, for a 4-year overall survival rate of 97%. Conclusions: Our analysis suggests that mucosal sparing RT after TOS in favorable risk oropharyngeal cancer patients may provide comparable oncologic and improved functional outcomes compared to conventional treatment in selected patients.

ABSTRACTIntroduction: We describe an unusual case of pleural drop metastases 21 years after complete resection of an encapsulated thymoma in a Southeast Asian patient with myasthenia gravis (MG). Methods: This investigation includes a case report and brief review of the literature. Results: The patient presented in 2015 with generalized weakness, fatigue, and shortness of breath, but no diplopia, ptosis, dysphagia, or dysarthria. Because these symptoms were atypical for an MG exacerbation, a de‐novo work‐up was performed. Chest computed tomography (CT) showed numerous pleural nodules (“drop metastases”), and CT‐guided biopsy revealed metastatic thymoma. Conclusions: The average disease‐free interval for thymoma ranges from 68 to 86 months. Pleural and mediastinal recurrence are more common than distant hematogenous recurrence. Adverse prognostic factors include an initial higher Masaoka stage, incomplete resection, older age, and pleural or pericardial involvement. Despite apparent complete resection of thymoma, clinicians should remain vigilant for recurrence for as long as 20 years after initial management. Long‐term follow‐up with radiologic surveillance is recommended. Muscle Nerve 56: 171–175, 2017

BackgroundThe Papanicolaou Society of Cytopathology has developed a set of guidelines for respiratory cytology including indications for cytologic testing, techniques for cytologic sampling, terminology and nomenclature for respiratory diseases, ancillary testing, and recommendations for postcytologic diagnosis follow‐up and management.MethodsAll documents are based on the expertise of the authors, an extensive literature review and discussions of the draft documents at national and international meetings over a 12‐month period. This document selectively presents the results of these discussions and reports a proposed standardized terminology scheme for respiratory cytology that correlates cytologic diagnosis with biologic behavior and patient management.ResultsThe classification and terminology scheme recommends a six‐tiered system composed of: nondiagnostic, negative, atypical, neoplastic (benign and neoplasms of low malignant potential), suspicious, and positive for malignancy.ConclusionThe scheme recommends statements on specimen adequacy followed by the major classification category and then a subclassification and/or comments section. Each of the six main diagnostic categories is associated with an estimated risk of malignancy. Subsequent documents will propose ancillary testing recommendations, techniques for cytologic sampling, indications for cytologic study and postcytologic diagnosis management and follow‐up recommendations. Diagn. Cytopathol. 2016;44:399–409. © 2016 Wiley Periodicals, Inc.

Epithelial‐myoepithelial carcinoma (EMC) is a rare salivary gland malignancy with variable cytologic findings. Its rarity, variable morphologic findings, and similarities with more common salivary gland entities make it a difficult cytologic diagnosis. As the name signifies, the key feature of this tumor is presence of an epithelial and myoepithelial component. However, when one of these two components is scant on the fine needle aspiration (FNA) smears, it may be overlooked. We present a case from a 62 year‐old female who presented to the clinic with a parotid nodule and episodes of sharp, throbbing pain. A fine needle aspiration was performed which revealed a highly cellular specimen comprised primarily of aggregates of cells with small, round nuclei and scant to absent cytoplasm. Abundant hyaline stromal material was also noted. The case was signed out as basaloid neoplasm with a recommendation for surgical resection. The subsequent resection specimen revealed EMC. By reviewing the FNA specimen following the surgical resection of the tumor, we were able to utilize the benefit of hindsight to more clearly identify the subtle, biphasic components of the tumor. Diagn. Cytopathol. 2016;44:422–425. © 2016 Wiley Periodicals, Inc.