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A problem in the diagnosis of Papanicolaou smears--the interpretation of "hyperchromatic crowded groups" (HCGs)--is identified and analyzed. HCGs usually represent benign entities such as endometrial cells, syncytial aggregates in severe atrophy, or fragments of endocervical tissue, the latter being seen with increasing frequency due to the use of the endocervical brush. Tubal metaplasia is another common, benign source of HCGs. However, occasionally HCGs represent serious lesions, such as carcinoma in situ, invasive squamous cell carcinoma, and glandular neoplasia, either in situ or invasive. The distinction among these various entities is not always easy, but guidelines are presented.

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Carcinoma of the breast is the most litigated cancer in women. This article discusses steps that can be taken to reduce the risk of being sued. Topics covered include laboratory practices, patient contact, informed consent, documentation, record keeping, interpretive problems, triple test, diligence, and reporting results as well as what to do if sued.

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No test ever invented has been as successful as the Papanicolaou smear in preventing cancer. Despite its remarkable success in cervical cancer prevention, however, the Papanicolaou smear is not a perfect test. Sampling errors account for a significant number of false-negative cases. Diagnostic errors occur in even the finest cytology laboratories. Yet, for women who develop cervical cancer, these errors pale in comparison with failure to screen patients adequately in the first place. This paper examines some of the problems that result in failure of the Papanicolaou smear to prevent cervical cancer, with an emphasis on common problems in Papanicolaou smear interpretation.

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The Papanicolaou smear has been a remarkably effective tool in cancer prevention, but it is not a perfect test. Although the most important factor in failure of cervical cancer prevention is lack of adequate screening, other factors include problems with sampling, interpretation, and effective clinical follow-up. A small number of rapidly developing cervical cancers probably also arise in the interval between Papanicolaou smear screenings. Consequently, cervical cancer will develop in some women despite appropriate screening. This article will analyze some of the problems relating to diagnostic errors, which include abnormal cells that are few (< 100), small, or bland.

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BACKGROUND: A number of histologic variants of papillary carcinoma of the thyroid have been described, including an oxyphil cell subtype (OVPC). Few OVPC cases have been detailed cytologically. CASES: Smears prepared from aspiration biopsies, as well as the corresponding histologic sections and clinical histories, were reviewed for three cases. Two patients had asymptomatic thyroid tumors, and the third developed neck tumors after thyroid cancer surgery. All smears revealed scattered papillary groups and monolayered sheets. The large, neoplastic cells had abundant, granular cytoplasm and eccentrically placed nuclei. Nuclear grooves and intranuclear inclusions were variably present. Psammoma bodies and colloid were not identified. Histologically the tumors consisted predominantly of oxyphil cells arranged in papillary patterns and with nuclear features of usual papillary carcinoma (UPC). CONCLUSION: OVPC can be diagnosed in smears composed predominantly of large oxyphil cells but showing features associated with UPC and can be cytologically distinguished from follicular oxyphilic tumors and UPC.

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Blast-like cells in the cerebrospinal fluid (CSF) of neonates have been identified and previously suggested to be of germinal matrix origin. Twelve additional CSF specimens with blast-like cells collected at the University of Texas Medical Branch, Galveston, between 1985-1992 were analyzed. The cytological features of the blast-like cells as well as their associated clinical setting were further characterized by the authors. All patients in the study were young infants with hydrocephalus and nearly all underwent placement of a ventriculoperitoneal (VP) shunt at the time the CSF specimen was collected. In addition, a cytologic preparation of germinal matrix cells obtained from an autopsy specimen was analyzed, which closely resembled the blast-like cells. These data provide additional evidence that blast-like cells originate from the germinal matrix.

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OBJECTIVE: To resolve the discrepancy that women seem to have Papanicolaou smears with dysplasia at younger ages than the reported mean ages. METHODS: Every other Papanicolaou smear diagnosed during a 5-year period at our institution was reviewed. There were 1947 cases with dysplasia or carcinoma. Dysplasia was defined as a lesion of disordered squamous epithelial differentiation and was graded by standard criteria. The mean, median, and mode ages of the women were determined by diagnosis. Normal (symmetrical) distribution was tested for each population, and significant differences were sought by diagnosis. RESULTS: Normal distribution was rejected for the ages of women with all grades of dysplasia and carcinoma in situ, but not for the ages of women with carcinoma. CONCLUSIONS: Because the ages of women with dysplasia are not distributed normally, but are asymmetrically skewed to younger women, we suggest that the mode better describes the central tendency for ages of women with dysplasia. The difference between the mean and mode ages of these women explains the apparent discrepancy between the reported mean ages and our clinical impression. Appropriate descriptive statistics like these help the clinician evaluate individual patients in the true context of the disease.

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The distribution of receptors for insulin and epidermal growth factor along the longitudinal axis of the uterine cavity was studied in 28 uteri obtained from women of reproductive age undergoing hysterectomy for benign conditions. Insulin binding to crude plasma membranes was higher (p less than 0.05) in the secretory than in the proliferative phase of the menstrual cycle in all uterine segments (fundus to cervix). Epidermal growth factor binding did not change during the menstrual cycle but the number of epidermal growth factor binding sites was higher in the cervix than in the fundus (p less than 0.05). Scatchard plots of binding data, obtained with crude plasma membranes from pooled uteri, were curvilinear; the high-affinity sites had dissociation constants of 1 to 4 nmol/L and receptor concentrations of 100 to 300 fmol/mg of protein, for both iodine 125-labeled insulin and 125I-labeled epidermal growth factor. In plasma membranes, obtained from another 15 uteri, mouse nerve growth factor (3.3 micrograms/ml) decreased the binding of insulin by an average of 17% (p less than 0.005); in the decidua of a pregnant uterus at 12 weeks Scatchard analysis showed that nerve growth factor decreased the affinity but not the number of insulin-binding sites. Nerve growth factor had no effect on epidermal growth factor binding. Human prolactin (2 micrograms/ml) also decreased insulin binding by an average of 18% (n = 5, p less than 0.025) but had no effect on epidermal growth factor binding. These "baseline" data will be useful in further studies of the possible interactions between (1) receptors for various peptide growth factors and (2) sex steroid hormones, in normal and neoplastic endometrium and cervix.

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A 65-year-old female presented with a one-and-a-half-year history of intermittent, painless, gross hematuria. She was found to have a large bladder neoplasm. A cytologic diagnosis of signet-ring-cell (colloid) carcinoma was made on a bladder washing and was confirmed histologically by a cystoscopic biopsy. Subsequently, a radical cystectomy was performed. The cytologic findings of this rare pure signet-ring-cell carcinoma of the bladder, not previously described, are presented along with the histologic and ultrastructural findings.

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A case of adrenal myelolipoma, to the authors' knowledge, the first diagnosed by fine-needle aspiration, is reported. Adrenal myelolipoma is an unusual, benign lesion with a distinctive cytologic appearance. Computed tomography (CT)-guided fine-needle aspiration of the adrenal gland involves minimal morbidity and provides rapid, reliable differentiation of this entity from a malignant neoplasm.

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Charts and slides of 47 patients with primary retroperitoneal sarcomas (excluding pediatric rhabdomyosarcoma) were reviewed to determine clinical presentation, histologic features, extent of surgical resection, operative morbidity and mortality, use of radiation and/or chemotherapy, and survival data. Most patients presented with pain and a palpable mass. Leiomyosarcomas and liposarcomas were the most common tumors. Eighteen of the 47 patients (38%) had complete tumor excision; 68% required resection of adjacent organs. Operative morbidity was 33% with no mortality. After complete resection, the disease-free 5-year survival was 50% and the overall survival was 70% at 5 years; 10-year disease-free survival was 25% with an overall 58% survival at 10 years. Eleven patients (61%) developed recurrent disease with a median interval of 5 years following complete excision. Six patients received adjuvant radiation and/or chemotherapy with four remaining disease-free from 46 to 61 months. Eighteen patients underwent partial excision of tumor and 11 patients underwent biopsy only; these groups had similar survival curves with only 4% alive at 5 years. Their operative morbidity was 18% and mortality was 7%; median time to clinical evidence of tumor progression was 12 months. Sixty per cent of these patients received therapeutic radiation and/or chemotherapy, but their survival was the same as those undergoing surgery alone. These data emphasize the importance of an aggressive surgical approach in the treatment of retroperitoneal sarcomas. Complete tumor resection and total excision of recurrences will allow many patients long-term survival.

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The clinicopathologic features of a malignant fibrous histiocytoma arising in a female breast are presented. Seven cases have been previously reported. These may be divided into three subgroups based on history and pathologic findings. Three of the seven occurred in women without a history of other tumors or previous irradiation. One appeared with a cystosarcoma phyllodes, and three arose following radiation for carcinoma of the breast. The patient in this study had received no radiation. Treatment has been based on surgical resection; the roles of chemotherapy and radiation are uncertain. Although resection alone in the first subgroup has lead to no reported mortality, the small number of cases and the relatively short follow-up does not allow a meaningful assessment of the prognosis in this disease.

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The natural history of malignant fibrous histiocytomas in children has not been well delineated. During a 6-year period, we have treated six patients less than 18 years of age. The sites of origin included the retroperitoneum in 2 patients, neck in 2 patients, and extremities in 2 patients. Surgical treatment consisted of wide local excision in 5 patients and amputation in 12; radiation and/or chemotherapy were administered to 2 patients following resection of all tumor. All children remain free of local recurrence or distant metastases with a median follow-up in excess of 4 years. These data suggest that malignant fibrous histiocytomas in children may have a better prognosis than in adults.

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