The cytologic findings of an extranodal NK/T-cell lymphoma (NKTCL) presenting as a large adrenal mass with leptomeningeal involvement diagnosed by CT-guided fine-needle aspiration and cerebrospinal fluid (CSF) cytology are described. The 65-year-old Caucasian patient presented with progressive headache and multiple cranial nerve neuropathies. Magnetic resonance imaging showed leptomeningeal enhancement surrounding the conus medullaris and cauda equine, and a subsequent PET/CT demonstrated a large right adrenal gland mass. Fine-needle aspiration of the adrenal mass showed occasional large pleomorphic cells with prominent nucleoli, moderate amounts of cytoplasm, and rare large cells with sparse cytoplasmic granules admixed with numerous small lymphocytes. Initial flow cytometry from this sample showed no clonal B-cell population. Immunoperoxidase stains performed on the cell block/core specimen showed that the large atypical cells were positive for CD2, CD30, CD43 and CD56, TIA-1, granzyme, and perforin, but for none of the other T-cell markers used (CD3, CD4, CD5, CD8, CD45RO), which stained the abundant background lymphocytes. A CSF specimen showed similar neoplastic cells and flow cytometry showed an NK-cell population with aberrant immunophenotype. The cytologic findings of the neoplastic cells and the extensive panel of immunoperoxidase stains allowed the diagnosis of NKTCL, which was confirmed by the subsequent flow-cytometric immunophenotyping performed on the CSF. This is, to the best of our knowledge, the first case of NKTCL diagnosed by FNA of the adrenal gland and by CSF cytology.

Wright-Giemsa staining is a common procedure that is performed routinely in hematology laboratories. Consistency in intra-laboratory staining quality is essential for accurate morphological interpretation of blood smears. Although the Wright-Giemsa stain can be challenging to perform, the methods illustrated here have provided consistent, high quality stains in the Special Hematology Laboratory at the University of Minnesota for over half a century. We outline methods for collecting blood specimens, preparing the slides and performing a Wright-Giemsa stain using our combination of reagents. Various techniques that have been passed down in our laboratory for troubleshooting suboptimally stained specimens are shared as well.

A previously healthy 37-year-old man first presented 2 years prior to the current admission with acute onset of abdominal pain, for which he underwent emergent cholecystectomy. The postoperative course was however, marked by increasingly severe right upper quadrant pain leading to his current admission. The patient had normal laboratory values, including CBC, amylase, and lipase on several occasions, but had mildly elevated AST, ALT, and serum calcium levels. On endoscopic retrograde cholangiopancreatography (ERCP) with sphincter of Oddi manometry, the pancreatic sphincter basal pressure was elevated, suggestive of sphincter dysfunction. The bile duct was dilated to 12 mm. EUS showed no mass lesions, but identified two simple pancreatic cystic structures with ultrasound features of pseudocysts measuring 0.8 3 0.5 and a 0.3 3 0.2 cm. The larger cyst was aspirated, returning one milliliter of clear fluid, from which Diff-Quik and Papanicolaou-stained smears, cytospins and cell block preparations were made. The quantity of aspirated fluid was insufficient to perform amylase and CEA determinations.

A 77-year-old female patient presented with a 1 month history of hemoptysis, fevers, chest discomfort, and increasing dyspnea on exertion. Her past medical history was significant for coronary artery bypass graft surgery 2 year previously, mixed hyperlipidemia and Ménière's disease. A chest CT scan was performed and showed multiple lung nodules measuring up to 3 cm in diameter in both lungs. The imaging findings were interpreted as most consistent with pulmonary metastases. A CT-guided core biopsy showed no evidence of malignancy but showed organizing pneumonitis with suppurative granulomas. Stains for acid fast bacilli (Fite), fungi (Gomori's methenamine silver, GMS), and bacteria (Brown-Brenn Gram) were negative for organisms, and the biopsy findings were felt to represent either an infection or Wegener's granulomatosis. The patient was placed on levofloxacin treatment with slight improvement of her symptoms. Further laboratory work-up did not support Wegener granulomatosis and blood cultures were negative. No lesions were identified bronchoscopically and the bronchoalveolar lavage (BAL) fluid showed 3,112 nucleated cells per lL, 85% of which were neutrophils and 10% monocytes or macrophages. Cytologic examination of Papanicolaou-stained smears prepared from the BAL sediment showed no organisms but the GMS-stained smears showed weakly staining long, slender (about 1 micron di-ameter) branching organisms (Fig. C-1). A Fite stain was performed on an additional smear and showed no acidfast organisms. Gram stains performed in the microbiology laboratory showed gram-positive beaded branching filamentous organisms (Fig. C-2), which were acid-fast on a modified Kinyoun stain.

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