Traditional Pap staining procedure involves immediate ethanol-fixation of prepared smears. When our department absorbed cytopathology services of an affiliate hospital using nonspecialized assistants, we had problems with poorly fixed slides. We evaluated an alternative approach of rehydration of air-dried slides in comparison to both immediate and delayed alcohol fixation for Pap staining. Fine needle aspirations were performed on deidentified unfixed autopsy tissue. Sampled tissues included lung, liver, thyroid, breast, and a mediastinal mass. Paired aspirate smears were immediately fixed, air-dried and rehydrated before staining, or delayed fixation after a 5-minute air dry (DF). Additional smears were Diff-Quik stained for comparison. Slides were Pap-stained at 0 days, 1 day, 3 days, or 5 days postaspiration and numerically scored for cytomorphologic feature quality. Data were compared with one-way analysis of variance analysis. We evaluated 237 pairs of smears. The immediately fixed and air-dried groups displayed higher quality for nuclear borders, nuclear detail, distinct cell borders, and cytoplasmic staining at every time point (all P values <0.05) compared to the DF group. Rehydration did not reverse the air-dry artifact from delayed fixation in the DF group. Air-drying with delayed rehydration/alcohol fixation maintains diagnostic quality in settings for which traditional preparative techniques are not optimal, technical assistance is limited, and transport is problematic. Our series demonstrates that air-dried slides maintained high quality when processed up to 5 days postaspiration. We demonstrate a technique that improves pathology outreach by providing better quality diagnostic material with minimal additional personnel costs.

INTRODUCTION:Traditional Pap staining procedure involves immediate ethanol-fixation of prepared smears. When our department absorbed cytopathology services of an affiliate hospital using nonspecialized assistants, we had problems with poorly fixed slides. We evaluated an alternative approach of rehydration of air-dried slides in comparison to both immediate and delayed alcohol fixation for Pap staining. MATERIALS AND METHODS:Fine needle aspirations were performed on deidentified unfixed autopsy tissue. Sampled tissues included lung, liver, thyroid, breast, and a mediastinal mass. Paired aspirate smears were immediately fixed, air-dried and rehydrated before staining, or delayed fixation after a 5-minute air dry (DF). Additional smears were Diff-Quik stained for comparison. Slides were Pap-stained at 0 days, 1 day, 3 days, or 5 days postaspiration and numerically scored for cytomorphologic feature quality. Data were compared with one-way analysis of variance analysis. RESULTS:We evaluated 237 pairs of smears. The immediately fixed and air-dried groups displayed higher quality for nuclear borders, nuclear detail, distinct cell borders, and cytoplasmic staining at every time point (all P values <0.05) compared to the DF group. Rehydration did not reverse the air-dry artifact from delayed fixation in the DF group. CONCLUSIONS:Air-drying with delayed rehydration/alcohol fixation maintains diagnostic quality in settings for which traditional preparative techniques are not optimal, technical assistance is limited, and transport is problematic. Our series demonstrates that air-dried slides maintained high quality when processed up to 5 days postaspiration. We demonstrate a technique that improves pathology outreach by providing better quality diagnostic material with minimal additional personnel costs.

Cholangiocarcinoma is an uncommon and aggressive malignancy of intrahepatic and extrahepatic bile ducts. We present a case of a 37-year-old woman with cholangiocarcinoma metastatic to the endometrium that mimicked a primary endometrial adenocarcinoma at resection. The patient is status-post orthotopic liver transplant for cholangiocarcinoma. She presented for evaluation of a clear, odorless vaginal discharge of 6 months’ duration. Endometrial biopsy demonstrated an adenocarcinoma with mucinous features similar to primary endometrial adenocarcinoma, but with an immunophenotype consistent with metastatic cholangiocarcinoma. Subsequent hysterectomy demonstrated complete replacement of the native endometrium, a presentation that represents, to our knowledge, the first such reported in the literature. Overall, extragenital metastatic disease to the uterine corpus is rare and involvement of the endometrium even less common. Metastatic cholangiocarcinoma represents a small subset of these metastases to the uterus.

Introduction Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancer-related death in the United States. The need for increased patient survival has not been met for PDAC. The addition of mannose to conventional chemotherapy leads to accumulation of mannose metabolite in cancer cells and increases subsequent cell death. This susceptibility to mannose depends on the levels of phosphomannose isomerase (PMI). The cancer cells with lower levels of PMI are more sensitive to mannose than cells with higher levels. In this study, we investigated the association of PMI expression with clinical and pathological features of PDAC cases. Methods PMI antibody immunohistochemistry (AbCam) was performed on tissue microarrays from 235 PDAC by a standard protocol on Ventana automated immunostainer. The PMI intensity was graded (0–3) and the proportion of positivity was scored. Correlation of PMI expression with staging and survival was analyzed. Results Of the 235 cases, 51.5% (n=121) cases demonstrated grade 2 intensity with 90.1% of these (n=109) showing positivity in ≥70% of tumor cells. Ninety-eight (41.7%) cases exhibited grade 3 intensity with 94.9% (n=93) of these cases showing ≥70% reactivity. Sixteen cases (6.8%) were nonreactive (intensity grade 0–1). Intensity of PMI expression was associated with significantly better prognosis as assessed by median survival in months (M): grade 0–1 intensity group: 11.2 M; grade 2 intensity group: 25.2 M; and grade 3 intensity group: 33.2 M (p=0.03). A minority (6.8%) of PDACs show non-high PMI expression with poorer prognosis. Discussion Mannose may be a particularly useful adjunct with chemotherapy to treat this aggressive subgroup. PMI expression is also a potential biomarker to predict the prognosis of PDAC.

1Department of Pathology and Immunology, Washington University, St Louis, MO, 63110, USA; 2Department of Pathology and Laboratory Medicine, University of Rochester, Rochester, NY, 14642, USA; 3Division of Biostatistics, Washington University, St Louis, MO, 63110, USA; 4Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA; 5Department of Pathology and Laboratory Medicine, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, 08901, USA Introduction: Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancerrelated death in the United States. The need for increased patient survival has not been met for PDAC. The addition of mannose to conventional chemotherapy leads to accumulation of mannose metabolite in cancer cells and increases subsequent cell death. This susceptibility to mannose depends on the levels of phosphomannose isomerase (PMI). The cancer cells with lower levels of PMI are more sensitive to mannose than cells with higher levels. In this study, we investigated the association of PMI expression with clinical and pathological features of PDAC cases. Methods: PMI antibody immunohistochemistry (AbCam) was performed on tissue microarrays from 235 PDAC by a standard protocol on Ventana automated immunostainer. The PMI intensity was graded (0–3) and the proportion of positivity was scored. Correlation of PMI expression with staging and survival was analyzed. Results: Of the 235 cases, 51.5% (n=121) cases demonstrated grade 2 intensity with 90.1% of these (n=109) showing positivity in ≥70% of tumor cells. Ninety-eight (41.7%) cases exhibited grade 3 intensity with 94.9% (n=93) of these cases showing ≥70% reactivity. Sixteen cases (6.8%) were nonreactive (intensity grade 0–1). Intensity of PMI expression was associated with significantly better prognosis as assessed by median survival in months (M): grade 0–1 intensity group: 11.2 M; grade 2 intensity group: 25.2 M; and grade 3 intensity group: 33.2 M (p=0.03). A minority (6.8%) of PDACs show non-high PMI expression with poorer prognosis. Discussion: Mannose may be a particularly useful adjunct with chemotherapy to treat this aggressive subgroup. PMI expression is also a potential biomarker to predict the prognosis of PDAC.

Background: Streptococcus pneumoniae (S. pneumoniae) is an uncommon cause of amniotic fluid infection and intrauterine fetal demise. Case report: A 39-year-old G8P2052 presented with preterm premature rupture of membrane at 22 weeks gestation and had a spontaneous vaginal delivery of a neonate who soon expired. Placental examination revealed retroplacental hematoma, acute necrotizing chorioamnionitis, acute three-vessel vasculitis and necrotizing funisitis of the umbilical cord. Postmortem examination demonstrated features of amniotic fluid infection syndrome with blood culture growing S. pneumoniae. Antenatal screening does not typically quantify S. pneumoniae infection, but small series have found vaginal colonization in fewer than 1% of women. Intrauterine or peritoneal infection derives primarily from ascending infection although other routes are hypothetically possible. Intra-amniotic and neonatal infections by S. pneumoniae are associated with high morbidity and mortality. Conclusion: S. pneumoniae should be considered in perinatal death of immature fetus with severe amniotic fluid infection syndrome and acute necrotizing funisitis.

Photoacoustic endoscopy offers in vivo examination of the visceral tissue using endogenous contrast, but its typical B-scan rate is similar to 10 Hz, restricted by the speed of the scanning unit and the laser pulse repetition rate. Here, we present a transvaginal fast-scanning optical-resolution photoacoustic endoscope with a 250-Hz B-scan rate over a 3-mm scanning range. Using this modality, we not only illustrated the morphological differences of vasculatures among the human ectocervix, uterine body, and sublingual mucosa but also showed the longitudinal and cross-sectional differences of cervical vasculatures in pregnant women. This technology is promising for screening the visceral pathological changes associated with angiogenesis. (C) The Authors. Published by SPIE under a Creative Commons Attribution 3.0 Unported License.

Endoscopic ultrasound guidedfine-needle aspiration (EUS-FNA) is useful for diagnosing pancreatic masses including metastases to the pancreas, which represent up to 7.6% of pancreatic masses. The aim of this study was to characterize solid pancreatic masses which were thought to represent metastases to the pancreas on pre-procedure imaging. We collected data on all such masses that were sampled by EUS-FNA at Washington University in St. Louis/Barnes Jewish Hospital. Medical records and the cytopathology database were retrospectively searched for pancreatic FNA that demonstrated metastatic disease. Data was gathered for tumor size, focality, and time period between primary tumor and metastasis, as well as immunohistochemistry staining. Pancreatic EUS procedures were performed in 618 patients to evaluate pancreatic masses , and FNA was performed in 442 patients from 2002 through 2017. 55 out of 442(12.4%) cases showed metastatic disease. The average size of metastatic lesions in their greatest dimension was 3.8 cm (range, 1.5-7.7 cm). The majority of tumors were unifocal in 47 out of 55 (85%).The most common metastatic lesion was renal cell carcinoma (24/55, 43%). The etiology of the other metastatic tumors included 8 non–small cell lung carcinoma, 7 colonic adenocarcinomas, 4 large B cell lymphoma, 3 breast adenocarcinomas, 2 transitional urothelial carcinomas, 1 ovarian serous carcinoma, and 1 mesenchymal chondrosarcoma, 2 liposarcoma, 1 adenoid cyst carcinoma, 1 melanoma, 1 leiomyosarcoma. Sixteen patients were reported to have neuroendocrine tumors in the pancreas which were either primary or secondary due to small lung cancer or carcinoid. The median time between diagnosis of primary tumor and initial pancreatic metastasis was 6.8 years (0-22 years). The most common metastasis to the pancreas in our study was renal cell carcinoma. A variety of other metastatic malignancies were also documented in this study. This underscores the importance of EUS guided FNA when pancreatic metastasis is suspected.